NR511 Midterm Exam
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
P: plan
What you will Rx
When to come back
Diagnostic tests
Pt education
Discuss minimum of three purposes of the written history and physical in relation to the importance
of documentation. - CORRECT 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 meCorrect answer of communicating info to all providers involved in pt's care
Is a medical-legal document
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
P: plan
What you will Rx
When to come back
Diagnostic tests
Pt education
Discuss minimum of three purposes of the written history and physical in relation to the importance
of documentation. - CORRECT 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 meCorrect answer of communicating info to all providers involved in pt's care
Is a medical-legal document
