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NR 511 Week 3 Assignment: SNAPPS Written Assignment plus SNAPPS ORAL Presentation
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NR 511 Week 3 Assignment: SNAPPS Written Assignment plus SNAPPS ORAL Presentation
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NR 511 FINAL QUESTIONS ANDVERIFIED ANSWERS|
Define,Diagnostic,Reasoning,-,ans--
To,solve,problems,,to,promote,health,,and,to,screen,for,disease,or,illness.,All,require,a,sensi
tivity,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,-,ans--
reports,,complaints,of,,,replies,to,provider,questions,,includes,ROS,,CC,,HPI
Discuss,and,identify,objective,data,-,ans--
what,you,can,see,,hear,,or,feel,as,part,of,a,clinical,exam.,Also,includes,laboratory,data,and,te
st,results.
Discuss,and,identify,the,components,of,and,HPI,-,ans--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,-,ans--
the,use,of,codes,to,communicate,with,payers,about,which,procedures,were,performed,and,
why
Medical,billing,-,ans--
the,process,of,submitting,and,following,up,on,claims,made,to,a,payer,in,order,to,receive,pay
ment,for,medical,services,rendered,by,a,healthcare,provider
2,Coding,Classification,systems,that,are,currently,used,in,the,US,healthcare,system,-,ans--
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,-,ans--referring,to,the,ability,of,the,test,to,correctly,detect,a,specific,condition
Sensitivity,-,ans--a,test,with,a,few,false,negatives
Predictive,value,-,ans--
likelihood,the,patient,actually,has,a,condition,and,is,in,part,dependent,upon,the,prevalence,o
f,the,condition,in,the,population
Elements,needed,when,developing,a,plan,-,ans--
acknowledge,the,list,,negotiate,what,to,cover,,be,honest,,make,a,follow,up
Components,of,medical,decision,making,(E&M),coding,-,ans--
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,pati
ent
Correctly,order,the,E&M,office,visits,based,on,complexity,from,least,to,most,complex,-,ans--
99212-99214
Discuss,a,minimum,of,three,purposes,of,the,written,H&P,in,relation,to,the,importance,of,doc
umentation,-,ans--
Important,reference,document,that,gives,concise,information,about,a,patient's,history,and,e
xam,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,p
atient's,condition
Means,of,communicating,information,to,all,providers,who,are,involved,in,the,care,of,a,particu
lar,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,cod
e,-,ans--
every,procedure,code,needs,a,diagnosis,to,explain,the,necessity,whether,the,code,represe
nts,an,actual,procedure,performed,or,a,nonprocedural,encounter,like,an,office,visit
,Correctly,identify,a,patient,as,a,new,patient,given,the,historical,information,-,ans--
one,who,has,not,received,professional,services,from,a,provider,from,the,same,group,practic
e,within,the,past,3,year.
Correctly,identify,a,patient,as,an,established,patient,given,the,historical,information,-,ans--
one,who,has,received,professional,service,from,a,provider,of,the,office,within,the,past,3,year
s
Identify,the,3,components,required,in,determining,an,outpatient,,office,visit,E&M,code,-,ans-
-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,y
ear
established-has,received,professional,care,within,3,year
Explain,what,a,well,rounded,clinical,experience,is,-,ans--
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,-,ans--<25%
State,9,things,that,must,be,documented,when,inputting,data,into,clinical,encounters,-,ans--
Date,of,service,,gender,and,ethnicity,,tests,performed,or,orderd,,visit,E&M,code,,chief,conce
rns,,diagnosis,,age,,procedures,,level,of,involvement
Identify,and,explain,each,part,of,the,acronym,SNAPPS,-,ans--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,-,ans--
viral:,norovirus-adults
rotovirus-0-2yrs
Assessing,for,prior,antibiotic,use,is,a,critical,part,of,the,history,in,patients,with,presenting,wit
h,_______________,due,to_________________,-,ans--Diarrhea/CDiff
Irritable,bowel,syndrome,-,ans--
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,-,ans--
chronic,immunologic,disease,that,manifests,in,intestinal,inflammation
Ulcerative,colitis
crohn's,disease
, Two,common,inflammatory,bowel,diseases,-,ans--Ulcerative,colitis-
mucosal,surface,of,the,colon,is,inflamed,and,ultimately,results,in,frability,,erosions,,and,blee
ding--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,b
owel,wall,and,any,portion,of,the,GI,tract,from,the,mouth,to,the,anus--
skipped,lesions,,pain,in,LLQ
Diverticulitis,-,ans--Symptoms:,LLQ,pain/tenderness,,fever,,N/V/D
Need,imagining,especially,if,perforation,or,peritonitis,is,suspected--
free,air=perforation;,patient,may,have,ileus,,small,or,large,bowel,obstruction
Can,use,plain,x-ray
CT,or,Barium,enema,are,preferred
CT,with,contrast,is,more,sensitive,and,accurate
Identify,the,significance,of,Barrett's,esophagus,-,ans--
After,repeated,exposure,to,gastric,contents,,inflammation,of,the,esophageal,mucosa,beco
mes,chronic
Blood,flow,increases,,erosion,occurs
As,erosion,heals,,normal,squamous,epithelium,replaced,with,metaplastic,columnar,epitheli
um,containing,goblet,and,columnar,cells.,
More,resistant,to,acid,and,supports,esophageal,healing
Premalignant,tissue
40-fold,frisk,for,developing,esophageal,adenocarcinma
Fibrosis,and,scarring,during,healing,of,erosions;,leads,to,strictures
Diagnosis,of,GERD,-,ans--made,on,history,alone:,sensitivity,of,80%,
if,symptoms,are,unclear/patient,does,not,respond,to,4,weeks,of,empiric,tx,
made,by,ambulatory,esophageal,pH,monitoring
pH,<4,above,the,lower,esophageal,sphincter,correlates,with,symptoms,=,GERD,
EDG,with,biopsy-Barrett's,esohagus
Normal,results,in,50%,of,symptomatic,patients
Risks,of,GERD,-,ans--Obesity
Increase,after,age,50
Equal,across,gender,,ethnic,,and,cultural,groups
Treatments,of,GERD,-,ans--Small,frequent,meals-main,meal,in,midday
Avoid,trigger,foods
No,bedtime,snacks:,no,eating,<4,hours,prior,to,bed
Eliminate,caffeine,,stop,smoking,,avoid,tight,fitting,clothing,,sleep,with,head,of,the,bed,eleva
ted.
Medications,for,GERD,-,ans--antacids,or,OTC,H2,(Tagamet,,zantac,,axid)
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