NR511 / NR 511 Midterm Exam Study Guide |Week 1 - 4|
(2025)
Define diagnostic reasoning - ANS-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? - ANS-Anything the patient tells you or complains of regarding
their symptoms
Chief complaint
HPI
ROS
What is objective data? - ANS-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 - ANS-Specifically related to the chief complaint only
Detailed breakdown of CC
OLDCARTS
Describe the differences between medical billing and medical coding. - ANS-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. - ANS-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? - ANS-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. - ANS-Pt's
preferences and actions
Research evidence
Clinical state/circumstances
Clinical expertise
Describe the components of medical decision making in E&M coding. - ANS-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. - ANS-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: - ANS-1. Diagnostics
2. Medication
3. Education
4. Referral/consultation
5. Follow-up planning
Define the components of a SOAP note. - ANS-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. - ANS-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? - ANS-
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? - ANS-Plan of service
Type of service
Patient status
Correctly ID a pt as a new or established given historical info. - ANS-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? - ANS-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?
- ANS-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? - ANS-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? - ANS-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)
(2025)
Define diagnostic reasoning - ANS-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? - ANS-Anything the patient tells you or complains of regarding
their symptoms
Chief complaint
HPI
ROS
What is objective data? - ANS-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 - ANS-Specifically related to the chief complaint only
Detailed breakdown of CC
OLDCARTS
Describe the differences between medical billing and medical coding. - ANS-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. - ANS-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? - ANS-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. - ANS-Pt's
preferences and actions
Research evidence
Clinical state/circumstances
Clinical expertise
Describe the components of medical decision making in E&M coding. - ANS-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. - ANS-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: - ANS-1. Diagnostics
2. Medication
3. Education
4. Referral/consultation
5. Follow-up planning
Define the components of a SOAP note. - ANS-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. - ANS-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? - ANS-
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? - ANS-Plan of service
Type of service
Patient status
Correctly ID a pt as a new or established given historical info. - ANS-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? - ANS-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?
- ANS-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? - ANS-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? - ANS-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)
