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NR511 Midterm Exam Study Guide

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NR511 Midterm Exam Study Guide Week 1 1. Define diagnostic reasoning: 2. Discuss and identify subjective & objective data 3. Discuss and identify the components of the HPI 4. Describe the differences between medical billing and medical coding 5. Compare and contrast the 2 coding classification systems that are currently used in the US healthcare system • Common Procedural Terminology (CPT) system: • International Classification of Diseases (ICD) system: 6. Discuss how specificity, sensitivity & predictive value contribute to the usefulness of the diagnostic data 7. Discuss the elements that need to be considered when developing a plan 8. Discuss a minimum of three purposes of the written history and physical in relation to the importance of documentation 9. Accurately document why every procedure code must have a corresponding diagnosis code 10. Correctly identify a patient as new or established given the historical information 11. Identify the 3 components required in determining an outpatient, office visit E&M code 12. Describe the components of Medical Decision Making in E&M coding 13. Correctly order the E&M office visit codes based on complexity from least to most complex New Established Minimal/RN visit Problem Focused Exp. Problem Focused Detailed Comprehensive 14. Explain what a “well rounded” clinical experience means 15. State the maximum number of hours that time can be spent “rounding” in a facility 16. State 9 things that must be documented when inputting data into clinical encounter 17. Identify and explain each part of the acronym SNAPPS Week 2 • Pain in abdomen relative to quadrants 1. Identify the most common type of pathogen responsible for acute gastroenteritis 2. Recognize that assessing for prior antibiotic use is a critical part of the history in patients presenting with diarrhea 3. Describe the difference between Irritable Bowel Syndrome (IBS) and Inflammatory Bowel Disorder (IBD) ......................................................continued............................................................................

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