NR 511 Midterm UPDATED ACTUAL
Questions and CORRECT Answers
Define diagnostic reasoning - CORRECT ANSWER -Reflective thinking because the
process involves questioning one's thinking to determine if all possible avenues have been
explored and if the conclusions that are being drawn are based on evidence.
Seen as a kind of critical thinking.
What is subjective data? - CORRECT ANSWER -Anything the patient tells you or
complains of regarding their symptoms
Chief complaint
HPI
ROS
What is objective data? - CORRECT ANSWER -Anything YOU can see, touch, feel, hear,
or smell as part of your exam
Includes lab data, diagnostic test results, etc.
Identify components of HPI - CORRECT ANSWER -Specifically related to the chief
complaint only
Detailed breakdown of CC
OLDCARTS
,Describe the differences between medical billing and medical coding. - CORRECT
ANSWER -Medical billing: process of submitting and following up on claims made to a
payer in order to receive payment for medical services rendered by a healthcare provider
Medical coding: the use of codes to communicate with payers about which procedures were
performed and why.
Compare and contrast the two coding classification systems that are currently used in the US
healthcare system. - CORRECT ANSWER -ICD: International classification of disease
codes are used to provide payer info on necessity of visit or procedure performed. Shorthand for
pt's dx.
CPT: common procedural terminology codes offer the official procedural coding rules and
guidelines required when reporting medical services and procedures performed by physician and
non-physician providers. Must have corresponding ICD.
How do specificity, sensitivity, and predictive value contribute to the usefulness of diagnostic
data? - CORRECT ANSWER -Specificity: ability of a test to correctly detect a specific
condition. If a pt has a condition but test is negative, it is a false negative. If pt does NOT have
condition but test is positive, it is false positive.
Sensitivity: test that has few false negatives. Ability of a test to correctly identify a specific
condition when it is present. The higher the sensitivity, the lesser the likelihood of a false
negative.
Predictive value: The likelihood that the pt actually has the condition and is, in part, dependent
upon the prevalence of the condition in the population. If a condition is highly likely, the positive
result would be more accurate.
Diagnostic tests can be used to confirm or rule out hypotheses.
Diagnostic tests may be used to screen for conditions.
,Diagnostic tests may be used to monitor the progress in managing a chronic condition.
Discuss the elements that need to be considered when developing a plan. - CORRECT
ANSWER -Pt's preferences and actions
Research evidence
Clinical state/circumstances
Clinical expertise
Describe the components of medical decision making in E&M coding. - CORRECT
ANSWER -Risk, data, diagnosis
The more time and consideration involved in dealing with a pt, the higher the reimbursement
from the payer.
Documentation must reflect MDM
Correctly order the E&M office visit codes based on complexity from least to most complex. -
CORRECT ANSWER -New pt:
1. Minimal/RN visit: 99201
2. Problem focused: 99202
3. Expanded problem focused: 99203
4. Detailed: 99204
5. Comprehensive: 99205
Established pt:
1. Minimal/RN visit: 99211
2. Problem focused: 99212
3. Expanded problem focused: 99213
4. Detailed: 99214
, 5. Comprehensive: 99215
The 5 key components of a comprehensive treatment plan are: - CORRECT ANSWER -1.
Diagnostics
2. Medication
3. Education
4. Referral/consultation
5. Follow-up planning
Define the components of a SOAP note. - CORRECT ANSWER -S: subjective (what the
pt tells you)
CC
HPI
PMH
Fam Hx
Social Hx
ROS
O: objective (what you can see, hear, feel on exam)
Physical findings
Vital signs
General survey
HEENT
Etc...
A: assessment
Global assessment of pt including differentials in order from most to least likely
Combination of subjective and objective info
List of dx addressed and billed for at the visit
Questions and CORRECT Answers
Define diagnostic reasoning - CORRECT ANSWER -Reflective thinking because the
process involves questioning one's thinking to determine if all possible avenues have been
explored and if the conclusions that are being drawn are based on evidence.
Seen as a kind of critical thinking.
What is subjective data? - CORRECT ANSWER -Anything the patient tells you or
complains of regarding their symptoms
Chief complaint
HPI
ROS
What is objective data? - CORRECT ANSWER -Anything YOU can see, touch, feel, hear,
or smell as part of your exam
Includes lab data, diagnostic test results, etc.
Identify components of HPI - CORRECT ANSWER -Specifically related to the chief
complaint only
Detailed breakdown of CC
OLDCARTS
,Describe the differences between medical billing and medical coding. - CORRECT
ANSWER -Medical billing: process of submitting and following up on claims made to a
payer in order to receive payment for medical services rendered by a healthcare provider
Medical coding: the use of codes to communicate with payers about which procedures were
performed and why.
Compare and contrast the two coding classification systems that are currently used in the US
healthcare system. - CORRECT ANSWER -ICD: International classification of disease
codes are used to provide payer info on necessity of visit or procedure performed. Shorthand for
pt's dx.
CPT: common procedural terminology codes offer the official procedural coding rules and
guidelines required when reporting medical services and procedures performed by physician and
non-physician providers. Must have corresponding ICD.
How do specificity, sensitivity, and predictive value contribute to the usefulness of diagnostic
data? - CORRECT ANSWER -Specificity: ability of a test to correctly detect a specific
condition. If a pt has a condition but test is negative, it is a false negative. If pt does NOT have
condition but test is positive, it is false positive.
Sensitivity: test that has few false negatives. Ability of a test to correctly identify a specific
condition when it is present. The higher the sensitivity, the lesser the likelihood of a false
negative.
Predictive value: The likelihood that the pt actually has the condition and is, in part, dependent
upon the prevalence of the condition in the population. If a condition is highly likely, the positive
result would be more accurate.
Diagnostic tests can be used to confirm or rule out hypotheses.
Diagnostic tests may be used to screen for conditions.
,Diagnostic tests may be used to monitor the progress in managing a chronic condition.
Discuss the elements that need to be considered when developing a plan. - CORRECT
ANSWER -Pt's preferences and actions
Research evidence
Clinical state/circumstances
Clinical expertise
Describe the components of medical decision making in E&M coding. - CORRECT
ANSWER -Risk, data, diagnosis
The more time and consideration involved in dealing with a pt, the higher the reimbursement
from the payer.
Documentation must reflect MDM
Correctly order the E&M office visit codes based on complexity from least to most complex. -
CORRECT ANSWER -New pt:
1. Minimal/RN visit: 99201
2. Problem focused: 99202
3. Expanded problem focused: 99203
4. Detailed: 99204
5. Comprehensive: 99205
Established pt:
1. Minimal/RN visit: 99211
2. Problem focused: 99212
3. Expanded problem focused: 99213
4. Detailed: 99214
, 5. Comprehensive: 99215
The 5 key components of a comprehensive treatment plan are: - CORRECT ANSWER -1.
Diagnostics
2. Medication
3. Education
4. Referral/consultation
5. Follow-up planning
Define the components of a SOAP note. - CORRECT ANSWER -S: subjective (what the
pt tells you)
CC
HPI
PMH
Fam Hx
Social Hx
ROS
O: objective (what you can see, hear, feel on exam)
Physical findings
Vital signs
General survey
HEENT
Etc...
A: assessment
Global assessment of pt including differentials in order from most to least likely
Combination of subjective and objective info
List of dx addressed and billed for at the visit
