NR 511 Final Exam Questions with Verified Answers (Correct
Update)
Question 1: Define Diagnostic Reasoning
Answer: To solve problems, to promote health, and to screen for disease or illness. All require a
sensitivity to complex stories, to contextual factors, and to sense of probability and uncertainty. Can be
seen as a kind of critical thinking.
Question 2: Discuss and identify subjective data
Answer: reports, complaints of , replies to provider questions, includes ROS, CC, HPI
Question 3: Discuss and identify objective data
Answer: what you can see, hear, or feel as part of a clinical exam. Also includes laboratory data and test
results.
Question 4: Discuss and identify the components of and HPI
Answer: OLDCARTS Onset of CC, Location of CC, Duration of CC, Characteristics of CC,
Aggravating factors of CC, Relieving factors of CC, Treatment of CC, Severity of CC
Question 5: Medical coding
Answer: the use of codes to communicate with payers about which procedures were performed and why
Question 6: Medical billing
Answer: the 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
Question 7: 2 Coding Classification systems that are currently used in the US healthcare system
Answer: CPT-recognized universally and provide logical means to be able to track healthcare data,
trends, and outcomes. ICD-10-shorthand for the patient's diagnosis, which are used to provide the payer
information on the necessity of the visit or procedures performed.
Question 8: Specificity
Answer: referring to the ability of the test to correctly detect a specific condition
Question 9: Sensitivity
Answer: a test with a few false negatives
Page 1
,Question 10: Predictive value
Answer: likelihood the patient actually has a condition and is in part dependent upon the prevalence of
the condition in the population
Question 11: Elements needed when developing a plan
Answer: acknowledge the list, negotiate what to cover, be honest, make a follow up
Question 12: Components of medical decision making (E&M) coding
Answer: history, physical, medical decision making E&M coding requires a medical decision maker a
way of quantifying the complexity of the thinking that is required for the visit-complexity=risk, data,
diagnosis MDM score gives credit for the excess work involved in management of a more complex
patient
Question 13: Correctly order the E&M office visits based on complexity from least to most
complex
Answer: 99212-99214
Question 14: Discuss a minimum of three purposes of the written H&P in relation to the
importance of documentation
Answer: Important reference document that gives concise information about a patient's history and exam
finding Outlines a plan for addressing the issues that prompted the visit. This information should be
presented in a logical fashion that prominently features all data immediately relevant to the patient's
condition Means of communicating information to all providers who are involved in the care of a
particular patient Important medical-legal document Essential in order to accurately code and bill for
services
Question 15: Accurately document why every procedure code must have a corresponding
diagnosis code
Answer: every procedure code needs a diagnosis to explain the necessity whether the code represents an
actual procedure performed or a nonprocedural encounter like an office visit
Question 16: Correctly identify a patient as a new patient given the historical information
Answer: one who has not received professional services from a provider from the same group practice
within the past 3 year.
Question 17: Correctly identify a patient as an established patient given the historical
information
Answer: one who has received professional service from a provider of the office within the past 3 years
Page 2
, Question 18: Identify the 3 components required in determining an outpatient, office visit E&M
code
Answer: place of service-inpatient, outpatient type of service-consultation, office visit, hospital
admission patient status-new-has not received professional service from a provider in the same practice
within the past 3 year established-has received professional care within 3 year
Question 19: Explain what a well rounded clinical experience is
Answer: Includes both children from birth through young adult visits for well child and acute visits, as
well as wellness, acute, and routine visits of adults
Question 20: What is the maximum number of hours that can be spent rounding in a facility
Answer: <25%
Question 21: State 9 things that must be documented when inputting data into clinical encounters
Answer: Date of service, gender and ethnicity, tests performed or orderd, visit E&M code, chief
concerns, diagnosis, age, procedures, level of involvement
Question 22: Identify and explain each part of the acronym SNAPPS
Answer: S-summarize, N-narrow, A-analyze, P-probe, Pplan-S-self-directing learning
Question 23: Identify the most common type of pathogen responsible for acute gastroenteritis
Answer: viral: norovirus-adults rotovirus-0-2yrs
Question 24: Assessing for prior antibiotic use is a critical part of the history in patients with
presenting with _______________ due to_________________
Answer: Diarrhea/CDiff
Question 25: Irritable bowel syndrome
Answer: disorder of the bowel function not from anatomic abnormality--constipation, diarrhea, bloating,
urgency w/diarrhea +s/s--result from disordered sensations or abnormal function of the small and large
bowel NOT associated with serious medical conditions, IBD, CA
Question 26: Inflammatory bowel disorder
Answer: chronic immunologic disease that manifests in intestinal inflammation Ulcerative colitis
crohn's disease
Page 3
Update)
Question 1: Define Diagnostic Reasoning
Answer: To solve problems, to promote health, and to screen for disease or illness. All require a
sensitivity to complex stories, to contextual factors, and to sense of probability and uncertainty. Can be
seen as a kind of critical thinking.
Question 2: Discuss and identify subjective data
Answer: reports, complaints of , replies to provider questions, includes ROS, CC, HPI
Question 3: Discuss and identify objective data
Answer: what you can see, hear, or feel as part of a clinical exam. Also includes laboratory data and test
results.
Question 4: Discuss and identify the components of and HPI
Answer: OLDCARTS Onset of CC, Location of CC, Duration of CC, Characteristics of CC,
Aggravating factors of CC, Relieving factors of CC, Treatment of CC, Severity of CC
Question 5: Medical coding
Answer: the use of codes to communicate with payers about which procedures were performed and why
Question 6: Medical billing
Answer: the 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
Question 7: 2 Coding Classification systems that are currently used in the US healthcare system
Answer: CPT-recognized universally and provide logical means to be able to track healthcare data,
trends, and outcomes. ICD-10-shorthand for the patient's diagnosis, which are used to provide the payer
information on the necessity of the visit or procedures performed.
Question 8: Specificity
Answer: referring to the ability of the test to correctly detect a specific condition
Question 9: Sensitivity
Answer: a test with a few false negatives
Page 1
,Question 10: Predictive value
Answer: likelihood the patient actually has a condition and is in part dependent upon the prevalence of
the condition in the population
Question 11: Elements needed when developing a plan
Answer: acknowledge the list, negotiate what to cover, be honest, make a follow up
Question 12: Components of medical decision making (E&M) coding
Answer: history, physical, medical decision making E&M coding requires a medical decision maker a
way of quantifying the complexity of the thinking that is required for the visit-complexity=risk, data,
diagnosis MDM score gives credit for the excess work involved in management of a more complex
patient
Question 13: Correctly order the E&M office visits based on complexity from least to most
complex
Answer: 99212-99214
Question 14: Discuss a minimum of three purposes of the written H&P in relation to the
importance of documentation
Answer: Important reference document that gives concise information about a patient's history and exam
finding Outlines a plan for addressing the issues that prompted the visit. This information should be
presented in a logical fashion that prominently features all data immediately relevant to the patient's
condition Means of communicating information to all providers who are involved in the care of a
particular patient Important medical-legal document Essential in order to accurately code and bill for
services
Question 15: Accurately document why every procedure code must have a corresponding
diagnosis code
Answer: every procedure code needs a diagnosis to explain the necessity whether the code represents an
actual procedure performed or a nonprocedural encounter like an office visit
Question 16: Correctly identify a patient as a new patient given the historical information
Answer: one who has not received professional services from a provider from the same group practice
within the past 3 year.
Question 17: Correctly identify a patient as an established patient given the historical
information
Answer: one who has received professional service from a provider of the office within the past 3 years
Page 2
, Question 18: Identify the 3 components required in determining an outpatient, office visit E&M
code
Answer: place of service-inpatient, outpatient type of service-consultation, office visit, hospital
admission patient status-new-has not received professional service from a provider in the same practice
within the past 3 year established-has received professional care within 3 year
Question 19: Explain what a well rounded clinical experience is
Answer: Includes both children from birth through young adult visits for well child and acute visits, as
well as wellness, acute, and routine visits of adults
Question 20: What is the maximum number of hours that can be spent rounding in a facility
Answer: <25%
Question 21: State 9 things that must be documented when inputting data into clinical encounters
Answer: Date of service, gender and ethnicity, tests performed or orderd, visit E&M code, chief
concerns, diagnosis, age, procedures, level of involvement
Question 22: Identify and explain each part of the acronym SNAPPS
Answer: S-summarize, N-narrow, A-analyze, P-probe, Pplan-S-self-directing learning
Question 23: Identify the most common type of pathogen responsible for acute gastroenteritis
Answer: viral: norovirus-adults rotovirus-0-2yrs
Question 24: Assessing for prior antibiotic use is a critical part of the history in patients with
presenting with _______________ due to_________________
Answer: Diarrhea/CDiff
Question 25: Irritable bowel syndrome
Answer: disorder of the bowel function not from anatomic abnormality--constipation, diarrhea, bloating,
urgency w/diarrhea +s/s--result from disordered sensations or abnormal function of the small and large
bowel NOT associated with serious medical conditions, IBD, CA
Question 26: Inflammatory bowel disorder
Answer: chronic immunologic disease that manifests in intestinal inflammation Ulcerative colitis
crohn's disease
Page 3
