NR511 Midterm Exam
Week 1
1. Define diagnostic reasoning
Reflective thinking because the process involves questioning one’s thinking to determining if all
possible avenues have been explored and if the conclusions th
...
NR511 Midterm Exam
Week 1
1. Define diagnostic reasoning
Reflective thinking because the process involves questioning one’s thinking to determining 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.
2. Discuss and identify subjective & objective data
- Subjective: What the pt tells you, complains of, etc. *Chief complaint, HPI, ROS
- Objective: What YOU can see, hear, or feel as part of your exam. *lab, data, dx test results.
3. Discuss and identify the components of the HPI
Specifically related to the CC only. Detailed breakdown of CC. OLDCART.
4. Describe the differences between medical billing and medical coding
- Medical coding: The use of codes to communicate with payers about which procedures were
performed and why
- 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.
5. Compare and contrast the 2 coding classification systems that are currently used
in the US healthcare system
- CPT codes: Common procedural terminology. Offers the official procedural coding rules and
guidelines required when reporting medical services and procedures performed by physician and
nonphysician orders.
- ICD codes: International classification of disease. Used to provide payer info on necessity of
visit or procedure performed.
6. Discuss how specificity, sensitivity & predictive value contribute to the usefulness
of the diagnostic data
- Specificity: The ability of the test to correctly detect a specific condition. If a patient has a
condition but test is negative, it is a false negative. If a patient does NOT have a condition but the
test is positive , it is a 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.
7. Discuss the elements that need to be considered when developing a plan
Patient’s preferences and actions. Research evidence. Clinical state/circumstances. Clinical
expertise.
8. Describe the components of Medical Decision Making in E&M coding
Risk – data – diagnosis. The more time and consideration involved in dealing with a pt, the higher
the reimbursement from the payer. Documentation must reflect the MDM!
9. Correctly order the E&M office visit codes based on complexity from least to most
complex
New patient:
1. Minimal/RN visit: 99201
2. Problem focused: 99202
3. Expanded problem focused: 99203
4. Detailed: 99204
5. Comprehensive: 99205
Established patient:
6. Minimal/RN patient: 99211
7. Problem focused: 99212
8. Expanded problem focused: 99213
9. Detailed: 99214
10. Comprehensive: 99215
10. Discuss a minimum of three purposes of the written history and physical in relation
to the importance of documentation
- Important reference document that vies 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 patient’s care.
- is a medical legal document
- is essential in order to accurately code and bill for services
11. Accurately document why every procedure code must have a corresponding
diagnosis code
Diagnosis code explains the necessity of the procedure code. Insurance won’t pay if they do not
correspond.
12. Correctly identify a patient as new or established given the historical information
New patient: If that patient has never been seen in that clinic or by that group of providers OR if the
pt has not been seen in the past 3 years
13. Identify the 3 components required in determining an outpatient, office visit E&M
code
Place of service, type of service, patient status.
14. Describe the components of Medical Decision Making in E&M coding
Risk – data – diagnosis
15. Correctly order the E&M office visit codes based on complexity from least to most
complex
· Repeat of #9?
New patient:
a. Minimal/RN visit: 99201
b. Problem focused: 99202
c. Expanded problem focused: 99203
d. Detailed: 99204
e. Comprehensive: 99205
Established patient:
f. Minimal/RN patient: 99211
g. Problem focused: 99212
h. Expanded problem focused: 99213
i. Detailed: 99214
j. Comprehensive: 99215
16. Explain what a “well rounded” clinical experience means
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 patients including 15% of peds and
15% of women’s health of total time in the program.
17. State the maximum number of hours that time can be spent “rounding” in a facility
No more than 25% of total practicum hours in the program
18. State 9 things that must be documented when inputting data into clinical encounter
1. Date of service
2. Age
3. Gender and Ethnicity
4. Visit E&M code
5. CC
6. Procedures
7. Tests performed and ordered
8. Dx
9. Level of involvement (mostly student, mostly preceptor, together, etc.)
19. Identify and explain each part of the acronym SNAPPS
- Summarize: present the pt’s H&P findings
- Narrow: based on the H&P findings, narrow down to the top 2-3 differentials
- Analyze: analyze the differentials. Compare and contrast H&P findings for each of the
differentials and narrow it down to the most likely one.
- Probe: ask the preceptor questions of anything you are unsure of.
- Plan: come up with a specific management plan
- Self-directed learning: an opportunity to investigate more about any topics that you are
uncertain of.
Week 2
1. Identify the most common type of pathogen responsible for acute gastroenteritis
Bacteria: Staphylococcus
Viral: Norovirus (Norwalk virus) in adults and Rotavirus in Peds up to 2 yrs old.
2. Recognize that assessing for prior antibiotic use is a critical part of the history in
patients presenting with diarrhea
Due to Risk for C Diff infection
3. Describe the difference between Irritable Bowel Disease (IBS) and Inflammatory
Bowel Disorder (IBD)
IBS (Irritable Bowel Disease)
○ a disorder of bowel function, not from anatomic abnormality;
○ characterized by alternating bowel pattern, constipation and diarrhea;
○ associated symptoms include abdo pain relieved w/defecation, bloating, rectal
urgency w/diarrhea;
○ Extra-intestinal symptoms: pain on intercourse or lack of libido, muscles
aches&pain, fatigue, fibromyalgia syndrome, headache, back pain, urinary
symptoms (urgency, hesitancy, bladder spasm);
○ Not associated with serious medical consequences; tend to live long;
○ Does not put stress on other organs (heart, liver, kidney)
○ Major problem of IBS: the quality of life that people suffer
Inflammatory Bowel Disorder (IBD)
● A chronic immunological disease that manifests in intestinal inflammation.
● Characterized by exacerbations and remissions throughout lifetime.
● UC and CD -- most common
4. Discuss two common Inflammatory Bowel Diseases
Ulcerative colitis (UC):
● the thinner mucosa of the rectum and sigmoid colon become inflamed, which results in
friability, erosions, and bleeding.
● More in male (age 10-40)
● Involved in the rectosigmoid areas, crypt
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