NR511 Midterm Exam Questions with Verified Answers (Correct
Update)
Question 1: Define diagnostic reasoning
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.
Question 2: What is subjective data?
Answer: Anything the patient tells you or complains of regarding their symptoms Chief complaint HPI
ROS
Question 3: What is objective data?
Answer: Anything YOU can see, touch, feel, hear, or smell as part of your exam Includes lab data,
diagnostic test results, etc.
Question 4: Identify components of HPI
Answer: Specifically related to the chief complaint only Detailed breakdown of CC OLDCARTS
Question 5: Describe the differences between medical billing and medical coding.
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.
Question 6: Compare and contrast the two coding classification systems that are currently used
in the US healthcare system.
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 nonphysician providers. Must have corresponding ICD.
Page 1
,Question 7: How do specificity, sensitivity, and predictive value contribute to the usefulness of
diagnostic data?
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.
Question 8: Discuss the elements that need to be considered when developing a plan.
Answer: Pt's preferences and actions Research evidence Clinical state/circumstances Clinical expertise
Question 9: Describe the components of medical decision making in E&M coding.
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
Question 10: Correctly order the E&M office visit codes based on complexity from least to most
complex.
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
Question 11: The 5 key components of a comprehensive treatment plan are:
Answer: 1. Diagnostics 2. Medication 3. Education 4. Referral/consultation 5. Follow-up planning
Question 12: Define the components of a SOAP note.
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 P: plan What
you will Rx When to come back Diagnostic tests Pt education
Page 2
, Question 13: Discuss minimum of three purposes of the written history and physical in relation to
the importance of documentation.
Answer: Important reference document that gives concise info about the pt's hx and exam findings
Outlines a plan for addressing issues that prompted the visit. Info should be presented in a logical
fashion that prominently features all data relevant to the pt's condition. Is a means of communicating
info to all providers involved in pt's care Is a medical-legal document Is essential in order to accurately
code and bill for services
Question 14: Why does every procedure code need a corresponding diagnosis code?
Answer: Diagnosis code explains the necessity of the procedure code. Insurance won't pay if they don't
correspond.
Question 15: What are the three components required in determining an outpatient, office visit
E&M code?
Answer: Plan of service Type of service Patient status
Question 16: Correctly ID a pt as a new or established given historical info.
Answer: Pt status: whether or not pt is new or established. New: has not received professional service
from provider in same group within past 3 years. Established: has received professional service from
provider in same group in last 3 years.
Question 17: What does a well-rounded clinical experience mean?
Answer: Includes seeing kids from birth through young adult visits for well child and acute visits, as
well as adults for wellness or acute/routine visits. Seeing a variety of pt's, including 15% of peds and
15% of women's health of total time in the program.
Question 18: What are the maximum number of hours that time can be spent "rounding" in a
facility?
Answer: No more than 25% of total practicum hours in the program
Question 19: What are 9 things that must be documented when inputting data into clinical
encounter logs?
Answer: Date of service Age Gender and ethnicity Visit E&M code CC Procedures Tests
performed/ordered Dx Level of involvement
Page 3
Update)
Question 1: Define diagnostic reasoning
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.
Question 2: What is subjective data?
Answer: Anything the patient tells you or complains of regarding their symptoms Chief complaint HPI
ROS
Question 3: What is objective data?
Answer: Anything YOU can see, touch, feel, hear, or smell as part of your exam Includes lab data,
diagnostic test results, etc.
Question 4: Identify components of HPI
Answer: Specifically related to the chief complaint only Detailed breakdown of CC OLDCARTS
Question 5: Describe the differences between medical billing and medical coding.
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.
Question 6: Compare and contrast the two coding classification systems that are currently used
in the US healthcare system.
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 nonphysician providers. Must have corresponding ICD.
Page 1
,Question 7: How do specificity, sensitivity, and predictive value contribute to the usefulness of
diagnostic data?
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.
Question 8: Discuss the elements that need to be considered when developing a plan.
Answer: Pt's preferences and actions Research evidence Clinical state/circumstances Clinical expertise
Question 9: Describe the components of medical decision making in E&M coding.
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
Question 10: Correctly order the E&M office visit codes based on complexity from least to most
complex.
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
Question 11: The 5 key components of a comprehensive treatment plan are:
Answer: 1. Diagnostics 2. Medication 3. Education 4. Referral/consultation 5. Follow-up planning
Question 12: Define the components of a SOAP note.
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 P: plan What
you will Rx When to come back Diagnostic tests Pt education
Page 2
, Question 13: Discuss minimum of three purposes of the written history and physical in relation to
the importance of documentation.
Answer: Important reference document that gives concise info about the pt's hx and exam findings
Outlines a plan for addressing issues that prompted the visit. Info should be presented in a logical
fashion that prominently features all data relevant to the pt's condition. Is a means of communicating
info to all providers involved in pt's care Is a medical-legal document Is essential in order to accurately
code and bill for services
Question 14: Why does every procedure code need a corresponding diagnosis code?
Answer: Diagnosis code explains the necessity of the procedure code. Insurance won't pay if they don't
correspond.
Question 15: What are the three components required in determining an outpatient, office visit
E&M code?
Answer: Plan of service Type of service Patient status
Question 16: Correctly ID a pt as a new or established given historical info.
Answer: Pt status: whether or not pt is new or established. New: has not received professional service
from provider in same group within past 3 years. Established: has received professional service from
provider in same group in last 3 years.
Question 17: What does a well-rounded clinical experience mean?
Answer: Includes seeing kids from birth through young adult visits for well child and acute visits, as
well as adults for wellness or acute/routine visits. Seeing a variety of pt's, including 15% of peds and
15% of women's health of total time in the program.
Question 18: What are the maximum number of hours that time can be spent "rounding" in a
facility?
Answer: No more than 25% of total practicum hours in the program
Question 19: What are 9 things that must be documented when inputting data into clinical
encounter logs?
Answer: Date of service Age Gender and ethnicity Visit E&M code CC Procedures Tests
performed/ordered Dx Level of involvement
Page 3
