NR 511 Final UPDATED ACTUAL
Questions and CORRECT Answers
Define Diagnostic Reasoning - CORRECT 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.
Discuss and identify subjective data - CORRECT ANSWER -reports, complaints of ,
replies to provider questions, includes ROS, CC, HPI
Discuss and identify objective data - CORRECT ANSWER -what you can see, hear, or
feel as part of a clinical exam. Also includes laboratory data and test results.
Discuss and identify the components of and HPI - CORRECT 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
Medical coding - CORRECT ANSWER -the use of codes to communicate with payers
about which procedures were performed and why
Medical billing - CORRECT 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
2 Coding Classification systems that are currently used in the US healthcare system - CORRECT
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.
Specificity - CORRECT ANSWER -referring to the ability of the test to correctly detect a
specific condition
Sensitivity - CORRECT ANSWER -a test with a few false negatives
Predictive value - CORRECT ANSWER -likelihood the patient actually has a condition
and is in part dependent upon the prevalence of the condition in the population
Elements needed when developing a plan - CORRECT ANSWER -acknowledge the list,
negotiate what to cover, be honest, make a follow up
Components of medical decision making (E&M) coding - CORRECT 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
Correctly order the E&M office visits based on complexity from least to most complex -
CORRECT ANSWER -99212-99214
Discuss a minimum of three purposes of the written H&P in relation to the importance of
documentation - CORRECT 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
Accurately document why every procedure code must have a corresponding diagnosis code -
CORRECT 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
Correctly identify a patient as a new patient given the historical information - CORRECT
ANSWER -one who has not received professional services from a provider from the same
group practice within the past 3 year.
Correctly identify a patient as an established patient given the historical information -
CORRECT ANSWER -one who has received professional service from a provider of the
office within the past 3 years
Identify the 3 components required in determining an outpatient, office visit E&M code -
CORRECT 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
Explain what a well rounded clinical experience is - CORRECT 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
What is the maximum number of hours that can be spent rounding in a facility - CORRECT
ANSWER -<25%
, State 9 things that must be documented when inputting data into clinical encounters - CORRECT
ANSWER -Date of service, gender and ethnicity, tests performed or orderd, visit E&M
code, chief concerns, diagnosis, age, procedures, level of involvement
Identify and explain each part of the acronym SNAPPS - CORRECT ANSWER -S-
summarize, N-narrow, A-analyze, P-probe, P-plan-S-self-directing learning
Identify the most common type of pathogen responsible for acute gastroenteritis - CORRECT
ANSWER -viral: norovirus-adults
rotovirus-0-2yrs
Assessing for prior antibiotic use is a critical part of the history in patients with presenting with
_______________ due to_________________ - CORRECT ANSWER -Diarrhea/CDiff
Irritable bowel syndrome - CORRECT 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
Inflammatory bowel disorder - CORRECT ANSWER -chronic immunologic disease that
manifests in intestinal inflammation
Ulcerative colitis
crohn's disease
Two common inflammatory bowel diseases - CORRECT ANSWER -Ulcerative colitis-
mucosal surface of the colon is inflamed and ultimately results in frability, erosions, and
bleeding--most common in recto-sigmoid colon. Can involve entire colon, pain in RLQ
Crohns disease-inflammation extends deeper into the intestional wall and can involve all or any
layer of the bowel wall and any portion of the GI tract from the mouth to the anus--skipped
lesions, pain in LLQ
Questions and CORRECT Answers
Define Diagnostic Reasoning - CORRECT 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.
Discuss and identify subjective data - CORRECT ANSWER -reports, complaints of ,
replies to provider questions, includes ROS, CC, HPI
Discuss and identify objective data - CORRECT ANSWER -what you can see, hear, or
feel as part of a clinical exam. Also includes laboratory data and test results.
Discuss and identify the components of and HPI - CORRECT 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
Medical coding - CORRECT ANSWER -the use of codes to communicate with payers
about which procedures were performed and why
Medical billing - CORRECT 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
2 Coding Classification systems that are currently used in the US healthcare system - CORRECT
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.
Specificity - CORRECT ANSWER -referring to the ability of the test to correctly detect a
specific condition
Sensitivity - CORRECT ANSWER -a test with a few false negatives
Predictive value - CORRECT ANSWER -likelihood the patient actually has a condition
and is in part dependent upon the prevalence of the condition in the population
Elements needed when developing a plan - CORRECT ANSWER -acknowledge the list,
negotiate what to cover, be honest, make a follow up
Components of medical decision making (E&M) coding - CORRECT 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
Correctly order the E&M office visits based on complexity from least to most complex -
CORRECT ANSWER -99212-99214
Discuss a minimum of three purposes of the written H&P in relation to the importance of
documentation - CORRECT 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
Accurately document why every procedure code must have a corresponding diagnosis code -
CORRECT 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
Correctly identify a patient as a new patient given the historical information - CORRECT
ANSWER -one who has not received professional services from a provider from the same
group practice within the past 3 year.
Correctly identify a patient as an established patient given the historical information -
CORRECT ANSWER -one who has received professional service from a provider of the
office within the past 3 years
Identify the 3 components required in determining an outpatient, office visit E&M code -
CORRECT 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
Explain what a well rounded clinical experience is - CORRECT 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
What is the maximum number of hours that can be spent rounding in a facility - CORRECT
ANSWER -<25%
, State 9 things that must be documented when inputting data into clinical encounters - CORRECT
ANSWER -Date of service, gender and ethnicity, tests performed or orderd, visit E&M
code, chief concerns, diagnosis, age, procedures, level of involvement
Identify and explain each part of the acronym SNAPPS - CORRECT ANSWER -S-
summarize, N-narrow, A-analyze, P-probe, P-plan-S-self-directing learning
Identify the most common type of pathogen responsible for acute gastroenteritis - CORRECT
ANSWER -viral: norovirus-adults
rotovirus-0-2yrs
Assessing for prior antibiotic use is a critical part of the history in patients with presenting with
_______________ due to_________________ - CORRECT ANSWER -Diarrhea/CDiff
Irritable bowel syndrome - CORRECT 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
Inflammatory bowel disorder - CORRECT ANSWER -chronic immunologic disease that
manifests in intestinal inflammation
Ulcerative colitis
crohn's disease
Two common inflammatory bowel diseases - CORRECT ANSWER -Ulcerative colitis-
mucosal surface of the colon is inflamed and ultimately results in frability, erosions, and
bleeding--most common in recto-sigmoid colon. Can involve entire colon, pain in RLQ
Crohns disease-inflammation extends deeper into the intestional wall and can involve all or any
layer of the bowel wall and any portion of the GI tract from the mouth to the anus--skipped
lesions, pain in LLQ
