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NR511 Midterm Questions And Verified Detailed Answers Graded A+
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NR511 Midterm Questions And Verified DetailedAnswers Graded A+
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.
-panel
Viewed as a type of critical thinking.
What is subjective data?-Answer Anything the patient tells you or complains of
regarding their symptoms
CC
HPI
ROS
Objective data-what is it? -Answer Anything YOU can see, touch, feel, hear or smell as
part of your exam
Lab data, diagnostic test results, etc.
Name elements of HPI -Answer Specifically related to the chief complaint only
Detailed breakdown of CC
OLDCARTS
Distinguish medical billing from medical coding. - Answer Medical billing: A process
where claims submitted to the payer are followed up to get paid for their services
rendered by a medical professional.
,Medical coding: The method of communicating with payers using codes for what
procedure is done and why.
Compare and contrast the two coding classification systems currently utilized within the
US healthcare system. - Answer ICD: International classification of disease codes are
utilized to provide the payor with information about the necessity of the visit or
procedure performed. Short hand for pt's dx.
CPT: Common Procedural Terminology codes provide official rules and guidelines for
coding procedures that are utilized when reporting medical services and procedures
provided by physician and non-physician providers. ICD must appear equivalently.
How do specificity, sensitivity, and predictive value contribute to the usefulness of
diagnostic data? - Answer Specificity: The 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: A test with few false negatives. Sensitivity means the ability of a certain test
to correctly identify a condition when it actually exists. The higher the sensitivity, the
less will be the chances of a false negative.
Predictive value: the likelihood of the pt actually having the condition and in part is
dependent upon the prevalence of the condition within the population. Therefore, if a
condition is highly likely, then the positive would be more valid.
The purpose for ordering a diagnostic test is to confirm or rule out hypotheses.
A diagnostic test may be ordered for screening purposes.
Diagnostic tests may also be ordered to monitor the progress of managing a chronic
condition.
List the considerations to be made in formulating a plan. - Pt's preferences and actions
,Research evidence
Clinical state/circumstances
Clinical expertise
Match the elements of medical decision making for E&M coding. - Risk, data, diagnosis
The greater the amount of time and judgment used in treating the pt, the more
challenging it is to treat the pt, the higher the compensation paid to the provider by the
payer.
Documentation must show MDM
Sequence the E&M office visit codes in order from least to most complex. - 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
Identify the 5 key components of a comprehensive plan of treatment. - 1. Diagnostics
2. Medication
3. Education
, 4. Referral/consultation
5. Follow-up planning
SOAP Note Components -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
What you will Rx
When to come back
Diagnostic tests
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