NR 511 Week 1-6 FINAL EXAM STUDY GUIDE Questions and Answers
WEEK 1
1. 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 arebeing drawn are based on evidence.
Seen as a kind of critical thinking.
2. Discuss and identify subjective data? What the
patient tells you, complains of, etc.Chief complaint
HPI
ROS
3. Discuss and identify objective data?
What YOU can see, hear, or feel as part of your exam.Includes lab data,
diagnostic test results.
Components of HPI
4. Discuss and identify the components of the HPISpecifically
related to the chief complaint only. Detailed breakdown of CC.
OLDCART
5. What is medical coding?
The use of codes to communicate with payers about which procedures were performedand why
6. What is medical billing?
Process of submitting and following up on claims made to a payer in order to receivepayment for medical services
rendered by a healthcare provider.
7. What are CPT codes?
Common procedural terminology
Offers the official procedural coding rules and guidelines required when reporting medical services and procedures
performed by physician and non-physician providers.
8. What are ICD codes?
International classification of disease
Used to provide payer info on necessity of visit or procedure performed.
9. What is specificity?
The ability of the test to correctly detect a specific condition.
If a patient has a condition but test is negative, it is a false negative.
If a patient does NOT have a condition but the test is positive, it is a false positive.
1
, 10. What is 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.
11. What is predictive value?
The likelihood that the patient actually has the condition and is, in part, dependent uponthe prevalence of the condition
in the population.
If a condition is highly likely, the positive result would be more accurate.
12. Discuss the elements that need to be considered when developing a plan
Pt's preferences and actionsResearch
evidence
Clinical state/circumstancesClinical
expertise
13. 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 thereimbursement from the payer.
Documentation must reflect MDM!
evaluation and management (E&M)
14. Correctly order the E&M office visit codes based on complexity from least to mostcomplex
New patient: Established patient:
1. Minimal/RN visit: 99201 Minimal RN visit: 99211
2. Problem focused: 99202 Problem focused: 99212
3. Expanded problem focused: 99203 Expanded problem focused: 99213
4. Detailed: 99204 Detailed: 99214
5. Comprehensive: 99205 Comprehensive: 99215
15. Discuss a minimum of three purposes of the written history and physical inrelation 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 thept's condition.
Is a means of communicating info to all providers involved in the pt's care.Is a medical-legal
document.
Is essential in order to accurately code and bill for services.
2
, 16. Accurately document why every procedure code must have a correspondingdiagnosis code
Diagnosis code explains the necessity of the procedure code.Insurance won't pay
if they don't correspond.
17. Correctly identify a patient as new or established given the historical information If that pt has never been
seen in that clinic or by that group of providers OR if thept has not been seen in the past 3 years.
18. Identify the 3 components required in determining an outpatient, office visit E&Mcode
Place of serviceType
of service Patient
status
19. 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 thereimbursement from the payer.
Documentation must reflect MDM!
evaluation and management (E&M)
20. Explain what a “well rounded” clinical experience means
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 timein the program.
21. State the maximum number of hours that time can be spent “rounding” in afacility
No more than 25% of total practicum hours in the program
22. State 9 things that must be documented when inputting data into clinicalencounter
Date of serviceAge
Gender and ethnicityVisit
E&M code
CC
Procedures
Tests performed and orderedDx
3
, Level of involvement (mostly student, mostly preceptor, together, etc.)
23. What is the first “S” in the SNAPPS presentation?
Summarize: present the pt's H&P findings
24. What is the “N” in the SNAPPS presentation?
Narrow: based on the H&P findings, narrow down to the top 2-3 differentials
25. What is the “A” in the SNAPPS presentation?
Analyze: analyze the differentials. Compare and contrast H&P findings for eachof the differentials and
narrow it down to the most likely one
26. What is the first “P” in the SNAPPS presentation?
Probe: ask the preceptor questions of anything you are unsure of.
27. What is the second “P” in the SNAPPS presentation?
Plan: come up with a specific management plan
.
28. What is the last “S” in the SNAPPS presentation?
Self-directed learning: an opportunity to investigate more about any topics that youare uncertain of.
4
WEEK 1
1. 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 arebeing drawn are based on evidence.
Seen as a kind of critical thinking.
2. Discuss and identify subjective data? What the
patient tells you, complains of, etc.Chief complaint
HPI
ROS
3. Discuss and identify objective data?
What YOU can see, hear, or feel as part of your exam.Includes lab data,
diagnostic test results.
Components of HPI
4. Discuss and identify the components of the HPISpecifically
related to the chief complaint only. Detailed breakdown of CC.
OLDCART
5. What is medical coding?
The use of codes to communicate with payers about which procedures were performedand why
6. What is medical billing?
Process of submitting and following up on claims made to a payer in order to receivepayment for medical services
rendered by a healthcare provider.
7. What are CPT codes?
Common procedural terminology
Offers the official procedural coding rules and guidelines required when reporting medical services and procedures
performed by physician and non-physician providers.
8. What are ICD codes?
International classification of disease
Used to provide payer info on necessity of visit or procedure performed.
9. What is specificity?
The ability of the test to correctly detect a specific condition.
If a patient has a condition but test is negative, it is a false negative.
If a patient does NOT have a condition but the test is positive, it is a false positive.
1
, 10. What is 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.
11. What is predictive value?
The likelihood that the patient actually has the condition and is, in part, dependent uponthe prevalence of the condition
in the population.
If a condition is highly likely, the positive result would be more accurate.
12. Discuss the elements that need to be considered when developing a plan
Pt's preferences and actionsResearch
evidence
Clinical state/circumstancesClinical
expertise
13. 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 thereimbursement from the payer.
Documentation must reflect MDM!
evaluation and management (E&M)
14. Correctly order the E&M office visit codes based on complexity from least to mostcomplex
New patient: Established patient:
1. Minimal/RN visit: 99201 Minimal RN visit: 99211
2. Problem focused: 99202 Problem focused: 99212
3. Expanded problem focused: 99203 Expanded problem focused: 99213
4. Detailed: 99204 Detailed: 99214
5. Comprehensive: 99205 Comprehensive: 99215
15. Discuss a minimum of three purposes of the written history and physical inrelation 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 thept's condition.
Is a means of communicating info to all providers involved in the pt's care.Is a medical-legal
document.
Is essential in order to accurately code and bill for services.
2
, 16. Accurately document why every procedure code must have a correspondingdiagnosis code
Diagnosis code explains the necessity of the procedure code.Insurance won't pay
if they don't correspond.
17. Correctly identify a patient as new or established given the historical information If that pt has never been
seen in that clinic or by that group of providers OR if thept has not been seen in the past 3 years.
18. Identify the 3 components required in determining an outpatient, office visit E&Mcode
Place of serviceType
of service Patient
status
19. 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 thereimbursement from the payer.
Documentation must reflect MDM!
evaluation and management (E&M)
20. Explain what a “well rounded” clinical experience means
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 timein the program.
21. State the maximum number of hours that time can be spent “rounding” in afacility
No more than 25% of total practicum hours in the program
22. State 9 things that must be documented when inputting data into clinicalencounter
Date of serviceAge
Gender and ethnicityVisit
E&M code
CC
Procedures
Tests performed and orderedDx
3
, Level of involvement (mostly student, mostly preceptor, together, etc.)
23. What is the first “S” in the SNAPPS presentation?
Summarize: present the pt's H&P findings
24. What is the “N” in the SNAPPS presentation?
Narrow: based on the H&P findings, narrow down to the top 2-3 differentials
25. What is the “A” in the SNAPPS presentation?
Analyze: analyze the differentials. Compare and contrast H&P findings for eachof the differentials and
narrow it down to the most likely one
26. What is the first “P” in the SNAPPS presentation?
Probe: ask the preceptor questions of anything you are unsure of.
27. What is the second “P” in the SNAPPS presentation?
Plan: come up with a specific management plan
.
28. What is the last “S” in the SNAPPS presentation?
Self-directed learning: an opportunity to investigate more about any topics that youare uncertain of.
4
