Chamberlain University-Illinois NR 511
NR511 Midterm Exam Study Guide &
Practice Questions/ NR 511 exam
answers
Terms in this set (140)
Define diagnostic reasoning 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? Anything the patient tells you or complains of regarding their
symptoms
Chief complaint
HPI
ROS
What is objective data? 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 Specifically related to the chief complaint only
Detailed breakdown of CC
OLDCARTS
Describe the differences between medical Medical billing: process of submitting and following up on
billing and medical coding. 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 ICD: International classification of disease codes are used to
classification systems that are currently used provide payer info on necessity of visit or procedure
in the US healthcare system. 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 Specificity: ability of a test to correctly detect a
predictive value contribute to the usefulness specific condition. If a pt has a condition but test is
of diagnostic data? 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 Pt's preferences and actions
considered when developing a plan. Research evidence
Clinical state/circumstances
Clinical expertise
,Describe the components of medical Risk, data, diagnosis
decision making in E&M coding.
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 New pt:
codes based on complexity from least 1. Minimal/RN visit: 99201
to most complex. 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 1. Diagnostics
treatment plan are: 2.Medication
3.Education
4. Referral/consultation
5. Follow-up planning
Define the components of a SOAP note. 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
, Discuss minimum of three purposes of Important reference document that gives concise info about
the written history and physical in relation the pt's hx and exam findings
to the importance of documentation.
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
Why does every procedure code need a Diagnosis code explains the necessity of the procedure code.
corresponding diagnosis code?
Insurance won't pay if they don't correspond.
What are the three components required in Plan of
determining an outpatient, office visit E&M service Type
code? of service
Patient status
Correctly ID a pt as a new or established Pt status: whether or not pt is new or established.
given historical info. 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.
What does a well-rounded Includes seeing kids from birth through young adult visits for
clinical experience mean? 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.
What are the maximum number of hours that No more than 25% of total practicum hours in the program
time can be spent "rounding" in a facility?
What are 9 things that must be Date of service
documented when inputting data into Age
clinical encounter logs? Gender and ethnicity
Visit E&M code
CC
Procedures
Tests performed/ordered
Dx
Level of involvement
NR511 Midterm Exam Study Guide &
Practice Questions/ NR 511 exam
answers
Terms in this set (140)
Define diagnostic reasoning 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? Anything the patient tells you or complains of regarding their
symptoms
Chief complaint
HPI
ROS
What is objective data? 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 Specifically related to the chief complaint only
Detailed breakdown of CC
OLDCARTS
Describe the differences between medical Medical billing: process of submitting and following up on
billing and medical coding. 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 ICD: International classification of disease codes are used to
classification systems that are currently used provide payer info on necessity of visit or procedure
in the US healthcare system. 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 Specificity: ability of a test to correctly detect a
predictive value contribute to the usefulness specific condition. If a pt has a condition but test is
of diagnostic data? 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 Pt's preferences and actions
considered when developing a plan. Research evidence
Clinical state/circumstances
Clinical expertise
,Describe the components of medical Risk, data, diagnosis
decision making in E&M coding.
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 New pt:
codes based on complexity from least 1. Minimal/RN visit: 99201
to most complex. 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 1. Diagnostics
treatment plan are: 2.Medication
3.Education
4. Referral/consultation
5. Follow-up planning
Define the components of a SOAP note. 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
, Discuss minimum of three purposes of Important reference document that gives concise info about
the written history and physical in relation the pt's hx and exam findings
to the importance of documentation.
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
Why does every procedure code need a Diagnosis code explains the necessity of the procedure code.
corresponding diagnosis code?
Insurance won't pay if they don't correspond.
What are the three components required in Plan of
determining an outpatient, office visit E&M service Type
code? of service
Patient status
Correctly ID a pt as a new or established Pt status: whether or not pt is new or established.
given historical info. 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.
What does a well-rounded Includes seeing kids from birth through young adult visits for
clinical experience mean? 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.
What are the maximum number of hours that No more than 25% of total practicum hours in the program
time can be spent "rounding" in a facility?
What are 9 things that must be Date of service
documented when inputting data into Age
clinical encounter logs? Gender and ethnicity
Visit E&M code
CC
Procedures
Tests performed/ordered
Dx
Level of involvement
