*NURSING > STUDY GUIDE > NR 511 Midterm Exam Study Guide (DETAILED 44 PAGES!!) (All)

NR 511 Midterm Exam Study Guide (DETAILED 44 PAGES!!)

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Week 1 1. Define diagnostic reasoning: type of critical thinking  Critical thinking involves the process of questioning one’s thinking to determine if all possible avenues have been explored a... nd if the conclusions that are being drawn are based on evidence  Diagnostic reasoning then includes a systematic way of thinking that evaluates each new piece of data as it either supports some diagnostic hypothesis or reduces the likelihood of others. 2. Discuss and identify subjective & objective data  Subjective: what the patient reports; complaints of; tells you  Example: fevers, chills, lethargy, headache, blurred vision, ST, etc.  Is the “S” part of the SOAP note which includes the CC, HPI, & ROS  Objective: what you can see, hear, or feel as part of your clinical exam; also includes laboratory data and tests results  Example: thin, obese, normocephalic, rapid stress test +, etc.  Is the “O” part of the SOAP note 3. Discuss and identify the components of the HPI  Should be focused on the complaint and relevant symptoms  Detailed breakdown of the CC, written out as the OLDCARTS acronym  Onset, Location, Duration, Characteristics, Aggravating Factors, Relieving Factors, Treatments, Severity.  Duration: not referring to the onset of the symptom. Rather, it is an assessment of whether the symptom is constant or if it comes and goes.  Severity: level of pain, impact on work/school or ADLs. 4. Describe the differences between medical billing and medical coding  Medical coding is the use of codes to communicate with payers about which procedures were performed and why  Medical billing, on the other hand, is the 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  Common Procedural Terminology (CPT) system: offers the official procedural coding rules and guidelines required when reporting medical services and procedures performed by physician and nonphysician providers  Recognized universally and also provide a logical means to be able to track healthcare data, trends, and outcomes. Each service or procedure is represented by a five-digit code that is presented in six sections, including 1. Evaluation & Management [Show More]

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