NR 511 Midterm Exam Week 4.

NR 511 Midterm Exam Week 4.1. Define diagnostic reasoning Reflective thinking because thhe process involves questioning one's thinking to determine if all possible avenues have been explored & if thhe conclusions that are being drawn are based on evidence. Seen as a kind of critical thinking. 2. What is subjective data? Anything thhe patient tells you or complains of regarding thheir symptoms Chief complaint HPI ROS 3. 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. 4. Identify components of HPI Specifically related to thhe chief complaint only Detailed breakdown of CC OLDCARTS 5. Describe thhe differences between medical billing & medical coding. Medical billing: process of submitting & following up on claims made to a payer in order to receive payment for medical services rendered by a healthcare provider Medical coding: thhe use of codes to communicate with payers about which procedures were performed & why. 6. Compare & contrast thhe two coding classification systems that are currently used in thhe US healthcare system. ICD: International classification of disease codes are used to provide payer info on necessity of visit or procedure performed. Shorth& for pt's dx.