Midterm Exam: NR511 / NR 511 (Latest
Update ) Differential
Diagnosis & Primary Care Practicum |
Exam Review Questions & Answers|
100% Correct | Grade A - Chamberlain
Define diagnostic reasoning - ANSWER 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? - ANSWER Anything the patient tells
you or complains of regarding their symptoms
Chief complaint
HPI
ROS
What is objective data? - ANSWER 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 - ANSWER Specifically related to the
chief complaint only
Detailed breakdown of CC
OLDCARTS
Describe the differences between medical billing and medical coding. -
ANSWER 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. - ANSWER 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? - ANSWER 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. -
ANSWER Pt's preferences and actions
Research evidence
Clinical state/circumstances
Clinical expertise
Describe the components of medical decision making in E&M coding. -
ANSWER 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. - ANSWER 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: - ANSWER
1. Diagnostics
2. Medication
3. Education
4. Referral/consultation
5. Follow-up planning
Define the components of a SOAP note. - ANSWER 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
Update ) Differential
Diagnosis & Primary Care Practicum |
Exam Review Questions & Answers|
100% Correct | Grade A - Chamberlain
Define diagnostic reasoning - ANSWER 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? - ANSWER Anything the patient tells
you or complains of regarding their symptoms
Chief complaint
HPI
ROS
What is objective data? - ANSWER 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 - ANSWER Specifically related to the
chief complaint only
Detailed breakdown of CC
OLDCARTS
Describe the differences between medical billing and medical coding. -
ANSWER 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. - ANSWER 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? - ANSWER 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. -
ANSWER Pt's preferences and actions
Research evidence
Clinical state/circumstances
Clinical expertise
Describe the components of medical decision making in E&M coding. -
ANSWER 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. - ANSWER 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: - ANSWER
1. Diagnostics
2. Medication
3. Education
4. Referral/consultation
5. Follow-up planning
Define the components of a SOAP note. - ANSWER 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
