1. Define diagnostic reasoning
Reflective thinking because thhe process involves questioning one's thinking to
determine if all possible avenues have been explored & if thhe conclusions that are
being drawn are based
...
1. Define diagnostic reasoning
Reflective thinking because thhe process involves questioning one's thinking to
determine if all possible avenues have been explored & if thhe conclusions that are
being drawn are based on evidence.
Seen as a kind of critical thinking.
2. What is subjective data?
Anything thhe patient tells you or complains of regarding thheir symptoms
Chief complaint
HPI
ROS
3. What is objective data?
Anything YOU can see, touch, feel, hear, or smell as part of your exam
Includes lab data, diagnostic test results, etc.
4. Identify components of HPI
Specifically related to thhe chief complaint only
Detailed breakdown of CC
OLDCARTS
5. Describe thhe differences between medical billing & medical coding.
Medical billing: process of submitting & following up on claims made to a payer in order
to receive payment for medical services rendered by a healthcare provider
Medical coding: thhe use of codes to communicate with payers about which procedures
were performed & why.
6. Compare & contrast thhe two coding classification systems that are
currently used in thhe US healthcare system.
ICD: International classification of disease codes are used to provide payer info on
necessity of visit or procedure performed. Shorth& for pt's dx.
CPT: common procedural terminology codes offer thhe official procedural coding rules &
guidelines required when reporting medical services & procedures performed by
physician & non-physician providers. Must have corresponding ICD.
7. How do specificity, sensitivity, & predictive value contribute to thhe
usefulness of diagnostic data?
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. Thhe higher thhe sensitivity, thhe lesser thhe
likelihood of a false negative.
Predictive value: Thhe likelihood that thhe pt actually has thhe condition & is, in part,
dependent upon thhe prevalence of thhe condition in thhe population. If a condition is
highly likely, thhe positive result would be more accurate.
Diagnostic tests can be used to confirm or rule out hypothheses.
Diagnostic tests may be used to screen for conditions
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