NR511 Midterm Exam
Study Guide
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 c
...
NR511 Midterm Exam
Study Guide
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 ref
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