NR511 Midterm QUESTIONS AND VERIFIED SOLUTIONS
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 billing and medical coding. - ✔✔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. -
✔✔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? - ✔✔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. - ✔✔Pt's preferences and
actions Research evidence Clinical state/circumstances Clinical expertise Describe the
components of medical decision making in E&M coding. - ✔✔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. - ✔✔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: - ✔✔1. Diagnostics 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 the written history
and physical in relation to the importance of documentation. - ✔✔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 Why does every procedure code
need a corresponding diagnosis code? - ✔✔Diagnosis code explains the necessity of the
procedure code. Insurance won't pay if they don't correspond. What are the three
components required in determining an outpatient, office visit E&M code? - ✔✔Plan of
service Type of service Patient status Correctly ID a pt as a new or established given
historical info. - ✔✔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. What does a
well-rounded clinical experience mean? - ✔✔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. What are the maximum number of hours that time can
be spent "rounding" in a facility? - ✔✔No more than 25% of total practicum hours in the
program What are 9 things that must be documented when inputting data into clinical
encounter logs? - ✔✔Date of service Age Gender and ethnicity Visit E&M code CC
Procedures Tests performed/ordered Dx Level of involvement What does the acronym
SNAPPS stand for? - ✔✔S: summarize (present pt's H&P findings) N: narrow (based on
H&P, narrow down top 2-3 differentials) A: analyze (compare/contrast H&P findings for
each differential and narrow it down to most likely one) P: probe (ask preceptor questions
of anything you are unsure of) P: plan (come up with specific management plan) S: Self-
directed learning (opportunity to investigate more about topics you are uncertain of) What
, is the most common type of pathogen responsible for acute gastroenteritis? - ✔✔Viral (can
be viral, bacterial, or parasitic), usually norovirus T/F Assessing for prior antibiotic use is a
critical part of the history in pt's presenting with diarrhea. - ✔✔True What is the difference
between irritable bowel disease (IBD) and irritable bowel syndrome (IBS)? - ✔✔IBS:
disorder of bowel function (as opposed to being due to an anatomic abnormality). Changes
in bowel habits (diarrhea, constipation, abd pain, bloating, rectal urgency w/diarrhea).
Symptoms fall into two categories: abd pain/altered bowel habits, and painless diarrhea.
Usually pain is LLQ. PE: normal except for tenderness in colon. Labs: CBC, ESR. Most other
labs and radiology/scopes are normal. Dx made on careful H&P. May be associated with
nonintestinal (extra-intestinal) symptoms (sexual function difficulty, muscle aches/pains,
fatigue, fibromyalgia, HAs, back pain, urinary symptoms). Not associate with serious
medical consequences. Not a risk factor for other serious GI dz's. Does not put extra stress
on other organs. Overall prognosis is excellent. Major problem: changes quality of life.
Treatment: based on symptom pattern. May include diet, education, pharm (for mod-
severe pt's)/other supportive interventions. Usually focuses on lifestyle, diet, and stress
reduction. NO PROVEN TREATMENT! Antidiarrheals: use temporarily, reserve for severe.
Loperamide (Imodium) or diphenoxylate (Lomotil) 2.5-5mg q6h usually works.
Constipation: high fiber diet, hydration, exercise, bulking agents. If these don't work,
intermittent use of stimulant laxatives (lactulose or mag hydroxide); don't use long-term!
Linzess (linaclotide), Trulance (plecanatide), and Amitiza (lubiprostone): newer for
constipation, work locally on apical membrane of GI tract to increase intestinal fluid
secretion and improve fecal transit. Abd pain: dicloclymine (Bentyl), hyoscyamine (avoid
anticholinergics in glaucoma and BPH, especially in elderly). TCAs and SSRIs can relieve
symptoms in some pt's. Can be managed by PCP, but if not responsive to tx, refer to GI.
IBD: chronic immunological dz that manifests in intestinal inflammation. UC and Crohn
What are two common IBD's? - ✔✔Ulcerative colitis Crohn's disease Describe the
characteristics of acute diverticulitis. - ✔✔Subjective: S/S of infection (fever, chills,
tachycardia) Localized pain LLQ Anorexia, n/v If fistula present, additional s/s will be
present associated w/affected organ (dysuria, pneumaturia, hematachzia, frank rectal
bleeding, etc) Objective: Tenderness in LLQ Maybe firm, fixed mass at area of diverticuli
Maybe rebound tenderness w/involuntary guarding/rigidity Hypoactive bowel sounds
initially, then hyperactive if obstructive process present Rectal tenderness +occult blood
Diagnostics: Mild-moderate leukocytosis Possibly decreased hgb/hct r/t rectal bleeding
Bladder fistula: urine will have increased WBC/RBC, culture may be + If peritonitis, blood
culture should be done (for bacteremia) Abd XR: perforation, peritonitis, ileus, obstruction
CT may be needed to confirm What is the difference between sensorineural and
conductive hearing loss? - ✔✔Sensorineural: results from deterioration of cochlea due to
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 billing and medical coding. - ✔✔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. -
✔✔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? - ✔✔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. - ✔✔Pt's preferences and
actions Research evidence Clinical state/circumstances Clinical expertise Describe the
components of medical decision making in E&M coding. - ✔✔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. - ✔✔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: - ✔✔1. Diagnostics 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 the written history
and physical in relation to the importance of documentation. - ✔✔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 Why does every procedure code
need a corresponding diagnosis code? - ✔✔Diagnosis code explains the necessity of the
procedure code. Insurance won't pay if they don't correspond. What are the three
components required in determining an outpatient, office visit E&M code? - ✔✔Plan of
service Type of service Patient status Correctly ID a pt as a new or established given
historical info. - ✔✔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. What does a
well-rounded clinical experience mean? - ✔✔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. What are the maximum number of hours that time can
be spent "rounding" in a facility? - ✔✔No more than 25% of total practicum hours in the
program What are 9 things that must be documented when inputting data into clinical
encounter logs? - ✔✔Date of service Age Gender and ethnicity Visit E&M code CC
Procedures Tests performed/ordered Dx Level of involvement What does the acronym
SNAPPS stand for? - ✔✔S: summarize (present pt's H&P findings) N: narrow (based on
H&P, narrow down top 2-3 differentials) A: analyze (compare/contrast H&P findings for
each differential and narrow it down to most likely one) P: probe (ask preceptor questions
of anything you are unsure of) P: plan (come up with specific management plan) S: Self-
directed learning (opportunity to investigate more about topics you are uncertain of) What
, is the most common type of pathogen responsible for acute gastroenteritis? - ✔✔Viral (can
be viral, bacterial, or parasitic), usually norovirus T/F Assessing for prior antibiotic use is a
critical part of the history in pt's presenting with diarrhea. - ✔✔True What is the difference
between irritable bowel disease (IBD) and irritable bowel syndrome (IBS)? - ✔✔IBS:
disorder of bowel function (as opposed to being due to an anatomic abnormality). Changes
in bowel habits (diarrhea, constipation, abd pain, bloating, rectal urgency w/diarrhea).
Symptoms fall into two categories: abd pain/altered bowel habits, and painless diarrhea.
Usually pain is LLQ. PE: normal except for tenderness in colon. Labs: CBC, ESR. Most other
labs and radiology/scopes are normal. Dx made on careful H&P. May be associated with
nonintestinal (extra-intestinal) symptoms (sexual function difficulty, muscle aches/pains,
fatigue, fibromyalgia, HAs, back pain, urinary symptoms). Not associate with serious
medical consequences. Not a risk factor for other serious GI dz's. Does not put extra stress
on other organs. Overall prognosis is excellent. Major problem: changes quality of life.
Treatment: based on symptom pattern. May include diet, education, pharm (for mod-
severe pt's)/other supportive interventions. Usually focuses on lifestyle, diet, and stress
reduction. NO PROVEN TREATMENT! Antidiarrheals: use temporarily, reserve for severe.
Loperamide (Imodium) or diphenoxylate (Lomotil) 2.5-5mg q6h usually works.
Constipation: high fiber diet, hydration, exercise, bulking agents. If these don't work,
intermittent use of stimulant laxatives (lactulose or mag hydroxide); don't use long-term!
Linzess (linaclotide), Trulance (plecanatide), and Amitiza (lubiprostone): newer for
constipation, work locally on apical membrane of GI tract to increase intestinal fluid
secretion and improve fecal transit. Abd pain: dicloclymine (Bentyl), hyoscyamine (avoid
anticholinergics in glaucoma and BPH, especially in elderly). TCAs and SSRIs can relieve
symptoms in some pt's. Can be managed by PCP, but if not responsive to tx, refer to GI.
IBD: chronic immunological dz that manifests in intestinal inflammation. UC and Crohn
What are two common IBD's? - ✔✔Ulcerative colitis Crohn's disease Describe the
characteristics of acute diverticulitis. - ✔✔Subjective: S/S of infection (fever, chills,
tachycardia) Localized pain LLQ Anorexia, n/v If fistula present, additional s/s will be
present associated w/affected organ (dysuria, pneumaturia, hematachzia, frank rectal
bleeding, etc) Objective: Tenderness in LLQ Maybe firm, fixed mass at area of diverticuli
Maybe rebound tenderness w/involuntary guarding/rigidity Hypoactive bowel sounds
initially, then hyperactive if obstructive process present Rectal tenderness +occult blood
Diagnostics: Mild-moderate leukocytosis Possibly decreased hgb/hct r/t rectal bleeding
Bladder fistula: urine will have increased WBC/RBC, culture may be + If peritonitis, blood
culture should be done (for bacteremia) Abd XR: perforation, peritonitis, ileus, obstruction
CT may be needed to confirm What is the difference between sensorineural and
conductive hearing loss? - ✔✔Sensorineural: results from deterioration of cochlea due to
