NR511 Midterm
1.Reflective thinking because the process involves questioning one's think-
ing to determine if all possible avenues have been explored and if the
conclu- sions that are being drawn are based on evidence.
Seen as a kind of critical thinking.: Define diagnostic reasoning
2.Anything the patient tells you or complains of regarding their symptoms
Chief complaint
HPI
ROS: What is subjective data?
3.Anything YOU can see, touch, feel, hear, or smell as part of your exam
Includes lab data, diagnostic test results, etc.: What is objective data?
4.Specifically related to the chief complaint
only Detailed breakdown of CC
OLDCARTS: Identify components of HPI
5.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.: Describe the differences between
medical billing and medical coding.
6.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.: Compare and contrast the two coding classification
systems that are currently used in the US healthcare system.
7.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
, NR511 Midterm
identify a specific condition when it is present. The higher the sensitivity, the
, NR511 Midterm
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.: How do specificity, sensitivity, and predictive value contribute
to the usefulness of diagnostic data?
8.Pt's preferences and actions
Research evidence
Clinical state/circumstances
Clinical expertise: Discuss the elements that need to be considered when
devel- oping a plan.
9.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: Describe the components of medical
decision making in E&M coding.
10.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: Correctly order the E&M office visit codes
based on complexity from least to most complex.
, NR511 Midterm
11.1. Diagnostics
2. Medication
3. Education
4. Referral/consultation
5. Follow-up planning: The 5 key components of a comprehensive
treatment plan are:
12.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: Define the components of a SOAP note.
13.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.
1.Reflective thinking because the process involves questioning one's think-
ing to determine if all possible avenues have been explored and if the
conclu- sions that are being drawn are based on evidence.
Seen as a kind of critical thinking.: Define diagnostic reasoning
2.Anything the patient tells you or complains of regarding their symptoms
Chief complaint
HPI
ROS: What is subjective data?
3.Anything YOU can see, touch, feel, hear, or smell as part of your exam
Includes lab data, diagnostic test results, etc.: What is objective data?
4.Specifically related to the chief complaint
only Detailed breakdown of CC
OLDCARTS: Identify components of HPI
5.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.: Describe the differences between
medical billing and medical coding.
6.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.: Compare and contrast the two coding classification
systems that are currently used in the US healthcare system.
7.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
, NR511 Midterm
identify a specific condition when it is present. The higher the sensitivity, the
, NR511 Midterm
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.: How do specificity, sensitivity, and predictive value contribute
to the usefulness of diagnostic data?
8.Pt's preferences and actions
Research evidence
Clinical state/circumstances
Clinical expertise: Discuss the elements that need to be considered when
devel- oping a plan.
9.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: Describe the components of medical
decision making in E&M coding.
10.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: Correctly order the E&M office visit codes
based on complexity from least to most complex.
, NR511 Midterm
11.1. Diagnostics
2. Medication
3. Education
4. Referral/consultation
5. Follow-up planning: The 5 key components of a comprehensive
treatment plan are:
12.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: Define the components of a SOAP note.
13.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.
