1
NR511 Final Exam
Study Guide
Week 1
1. Define diagnostic reasoning
To solve problems and promote health screen for diseases or illness
Diagnostic reasoning can be seen as critical thinking
Critical thinking involves the process of questioning one thinking to determine possible
avenues
Diagnostic reason is a systemic way of thinking and evaluates each piece of data with
some diagnostic hypothesis
2. Discuss and identify subjective & objective data
objective you can see, hear and feel
subjective- things a patient reports (CC, HPI, & ROS)
3. Discuss and identify the components of the HPI
OLDCARTS
O- ONSET / L: location./ D: Duration / C: Characteristics / A: aggravating/ R: Reliving factors/
T: Treatments tried and S: Severity
4. Describe the differences between medical billing and medical coding
Medical coding: codes communicated with payer of what procedures were preformed and
why
Medical billing: process of submitting and following up on claims made to payer to
receive payment
5. Compare and contrast the 2 coding classification systems that are currently used in the US
healthcare system
CPT- procedural coding on procedures, performed by non physican providers
ICD 10- short hand to provide payer information of visit or procedure preformed
6. Discuss how specificity, sensitivity & predictive value contribute to the usefulness of the
diagnostic data
Sensitivity- few false negatives
Specificity – correctly detect specific conditions
Predictive- likelihood the patient has the condition
7. Discuss the elements that need to be considered when developing a plan
Acknowledge the list
Negotiate what to cover
Be honest
Make a follow up
8. Describe the components of Medical Decision Making in E&M coding
History// physical ///medical decision making ( MDM)
Another way: risk/// data///dx
MDM score gives credit for excess work involved in management of complex pt’s
9. Correctly order the E&M office visit codes based on complexity from least to most complex
99212-99214
10. Discuss a minimum of three purposes of the written history and physical in relation to the
importance of documentation
Important reference document with concise information of pt hx/exam
Outlines a plan in addressing issues for the visit
Communicating information to all providers involved
1
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, 2
Important medical legal document
Accurately code and bill for services
11. Accurately document why every procedure code must have a corresponding diagnosis code
Explanation of necessity whether the code represents an actual procedure or non-
procedural encounter in the office
12. Correctly identify a patient as new or established given the historical information
New patient: more than 3 years since a visit
Established seen with in the last 3 years
13. Identify the 3 components required in determining an outpatient, office visit E&M code
Plan of service
In patient or out patient
Type of service- consultations office visit or hospital admission
14. Describe the components of Medical Decision Making in E&M coding
History/// physical/// MDM
Complexity: risk/// data/// diagnosis
15. Correctly order the E&M office visit codes based on complexity from least to most complex
99212-99214
16. Explain what a “well rounded” clinical experience means
From birth to death
15% pedi
15% womens health
17. State the maximum number of hours that time can be spent “rounding” in a facility
25%
18. State 9 things that must be documented when inputting data into clinical encounter
DOS: AGE: GENDER: ETHINICITY: E&M CODE: CC: procedures: test: diagnosis :
level of involvement
19. Identify and explain each part of the acronym SNAPPS
S- SUBJECTIVE
N- NARROW
A- ANALYZE
P- PROBE
P- PLAN
S- SELF DIRECTED LEARNING
Week 2
1. Identify the most common type of pathogen responsible for acute gastroenteritis
Norovirus- adult
Rotovirus – child
2. Describe an intervention for a patient with gastroenteritis
Support fluid repletion and nutrition
BRAT diet
Education on spread of disease ( viral)
Imodium or Zofran
3. Recognize that assessing for prior antibiotic use is a critical part of the history in patients
presenting with diarrhea
Risk for C diff
4. Discuss an appropriate treatment for prophylaxis or treatment of traveler's diarrhea
Bactrim ds 1 tab tid
2
This study source was downloaded by 100000900339724 from CourseHero.com on 09-04-2025 07:29:48 GMT -05:00
https://www.coursehero.com/file/32816003/NR511-Final-Exam-Study-Guideretype-practice-docx/
NR511 Final Exam
Study Guide
Week 1
1. Define diagnostic reasoning
To solve problems and promote health screen for diseases or illness
Diagnostic reasoning can be seen as critical thinking
Critical thinking involves the process of questioning one thinking to determine possible
avenues
Diagnostic reason is a systemic way of thinking and evaluates each piece of data with
some diagnostic hypothesis
2. Discuss and identify subjective & objective data
objective you can see, hear and feel
subjective- things a patient reports (CC, HPI, & ROS)
3. Discuss and identify the components of the HPI
OLDCARTS
O- ONSET / L: location./ D: Duration / C: Characteristics / A: aggravating/ R: Reliving factors/
T: Treatments tried and S: Severity
4. Describe the differences between medical billing and medical coding
Medical coding: codes communicated with payer of what procedures were preformed and
why
Medical billing: process of submitting and following up on claims made to payer to
receive payment
5. Compare and contrast the 2 coding classification systems that are currently used in the US
healthcare system
CPT- procedural coding on procedures, performed by non physican providers
ICD 10- short hand to provide payer information of visit or procedure preformed
6. Discuss how specificity, sensitivity & predictive value contribute to the usefulness of the
diagnostic data
Sensitivity- few false negatives
Specificity – correctly detect specific conditions
Predictive- likelihood the patient has the condition
7. Discuss the elements that need to be considered when developing a plan
Acknowledge the list
Negotiate what to cover
Be honest
Make a follow up
8. Describe the components of Medical Decision Making in E&M coding
History// physical ///medical decision making ( MDM)
Another way: risk/// data///dx
MDM score gives credit for excess work involved in management of complex pt’s
9. Correctly order the E&M office visit codes based on complexity from least to most complex
99212-99214
10. Discuss a minimum of three purposes of the written history and physical in relation to the
importance of documentation
Important reference document with concise information of pt hx/exam
Outlines a plan in addressing issues for the visit
Communicating information to all providers involved
1
This study source was downloaded by 100000900339724 from CourseHero.com on 09-04-2025 07:29:48 GMT -05:00
https://www.coursehero.com/file/32816003/NR511-Final-Exam-Study-Guideretype-practice-docx/
, 2
Important medical legal document
Accurately code and bill for services
11. Accurately document why every procedure code must have a corresponding diagnosis code
Explanation of necessity whether the code represents an actual procedure or non-
procedural encounter in the office
12. Correctly identify a patient as new or established given the historical information
New patient: more than 3 years since a visit
Established seen with in the last 3 years
13. Identify the 3 components required in determining an outpatient, office visit E&M code
Plan of service
In patient or out patient
Type of service- consultations office visit or hospital admission
14. Describe the components of Medical Decision Making in E&M coding
History/// physical/// MDM
Complexity: risk/// data/// diagnosis
15. Correctly order the E&M office visit codes based on complexity from least to most complex
99212-99214
16. Explain what a “well rounded” clinical experience means
From birth to death
15% pedi
15% womens health
17. State the maximum number of hours that time can be spent “rounding” in a facility
25%
18. State 9 things that must be documented when inputting data into clinical encounter
DOS: AGE: GENDER: ETHINICITY: E&M CODE: CC: procedures: test: diagnosis :
level of involvement
19. Identify and explain each part of the acronym SNAPPS
S- SUBJECTIVE
N- NARROW
A- ANALYZE
P- PROBE
P- PLAN
S- SELF DIRECTED LEARNING
Week 2
1. Identify the most common type of pathogen responsible for acute gastroenteritis
Norovirus- adult
Rotovirus – child
2. Describe an intervention for a patient with gastroenteritis
Support fluid repletion and nutrition
BRAT diet
Education on spread of disease ( viral)
Imodium or Zofran
3. Recognize that assessing for prior antibiotic use is a critical part of the history in patients
presenting with diarrhea
Risk for C diff
4. Discuss an appropriate treatment for prophylaxis or treatment of traveler's diarrhea
Bactrim ds 1 tab tid
2
This study source was downloaded by 100000900339724 from CourseHero.com on 09-04-2025 07:29:48 GMT -05:00
https://www.coursehero.com/file/32816003/NR511-Final-Exam-Study-Guideretype-practice-docx/
