Midterm Exam: NR511 / NR 511 (Latest
Update 2024 / 2025) 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. 1 / 4
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. 2 / 4
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 3 / 4
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
- Diagnostics
- Medication
- Education
- Referral/consultation
- 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
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