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

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 and if the conclusions th ...

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 and 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