NR 570 Final Exam Complete Study Guide
with Questions and Answers | Guarantee
Pass
1. Inpatient - ANSWER Admission expected to last ≥2 midnights; eligible for
Medicare Part A.
2. Observation - ANSWER Short-term treatment/testing to determine if
admission is needed; covered under Medicare Part B.
3. Emergency Department (ED) - ANSWER Evaluation and management
services for unscheduled care.
4. Family History (FH) - ANSWER Relevant medical conditions in family
members.
5. Review of Systems (ROS) - ANSWER A comprehensive, head-to-toe
inquiry about symptoms in various body systems.
6. Physical Examination (PE) - ANSWER Objective findings from the
physical assessment of all body systems.
7. Assessment/Plan - ANSWER Overall medical opinion of the patient's
condition, diagnosis, and initial treatment plan.
8. Discharge Summary - ANSWER Summarizes a patient's hospital stay,
facilitating continuity of care for post-discharge providers.
,9. Patient Information - ANSWER Name, age, gender, medical record
number, admission/discharge dates, and primary/admitting physicians.
10.Chief Complaint and Reason for Hospitalization - ANSWER Brief
description of the main symptoms leading to admission.
11.Past Medical History, Family History, and Social History - ANSWER
Summary of relevant history.
12.Hospital Course - ANSWER Details of diagnostic tests, procedures,
treatments, interventions, consultations, and any complications during the
stay.
13.Discharge Medications - ANSWER Comprehensive list of medications,
including changes, dosage, route, frequency, and indication.
14.Discharge Instructions - ANSWER Follow-up appointments, referrals,
specific instructions (wound care, diet, activity), and warning signs.
15.Discharge Disposition - ANSWER Patient's destination (home, skilled
nursing facility, etc.) and arrangements for services.
16.Signature and Date - ANSWER Of the healthcare provider completing the
summary.
17.Consultation Note - ANSWER Documents a request for an opinion or
advice from another healthcare provider or specialist regarding a specific
patient issue.
,18.ID - ANSWER Patient's name, age, gender, and code status (if inpatient).
19.Reason for Referral/Consult - ANSWER Clearly state why the consultation
was requested.
20.Outpatient - ANSWER Services provided without an overnight stay (e.g.,
clinic visits, same-day surgery).
21.Telehealth/Virtual - ANSWER Encounters conducted via video or phone,
billed under specific CMS guidelines.
22.CPT Codes - ANSWER Represent procedures and services rendered by
healthcare providers.
23.Category I CPT Codes - ANSWER Common services (e.g., 99214 for
outpatient E/M).
24.Category II CPT Codes - ANSWER Performance measurement codes
(optional).
25.Category III CPT Codes - ANSWER Emerging technologies.
26.ICD-10 Codes - ANSWER Used to document diagnoses and support
medical necessity.
27.Evaluation & Management (E/M) Codes - ANSWER Reflect complexity
and time of visit or care provided.
, 28.Level 1 Care - ANSWER Stable condition, minor treatment (e.g., office
visit).
29.Level 2-3 Care - ANSWER Acute illness, moderate complexity (e.g., chest
pain workup).
30.Level 4-5 Care - ANSWER Severe illness, potential for life-threatening
deterioration (e.g., ICU).
31.Hospital Levels - ANSWER SNF (Skilled Nursing Facility), IRF (Inpatient
Rehab Facility), LTAC (Long-Term Acute Care).
32.Role of the Hospitalist - ANSWER A provider who manages the care of
hospitalized patients.
33.Chief Complaint (CC) - ANSWER The primary reason the patient is
seeking care, ideally in their own words.
34.History of Present Illness (HPI) - ANSWER A chronological and detailed
narrative of the chief complaint.
35.Past Medical History (PMH) - ANSWER Significant medical conditions,
surgeries, hospitalizations, and treatments.
36.Medications - ANSWER Current medications, dosages, routes, and
frequencies, noting any discrepancies.
with Questions and Answers | Guarantee
Pass
1. Inpatient - ANSWER Admission expected to last ≥2 midnights; eligible for
Medicare Part A.
2. Observation - ANSWER Short-term treatment/testing to determine if
admission is needed; covered under Medicare Part B.
3. Emergency Department (ED) - ANSWER Evaluation and management
services for unscheduled care.
4. Family History (FH) - ANSWER Relevant medical conditions in family
members.
5. Review of Systems (ROS) - ANSWER A comprehensive, head-to-toe
inquiry about symptoms in various body systems.
6. Physical Examination (PE) - ANSWER Objective findings from the
physical assessment of all body systems.
7. Assessment/Plan - ANSWER Overall medical opinion of the patient's
condition, diagnosis, and initial treatment plan.
8. Discharge Summary - ANSWER Summarizes a patient's hospital stay,
facilitating continuity of care for post-discharge providers.
,9. Patient Information - ANSWER Name, age, gender, medical record
number, admission/discharge dates, and primary/admitting physicians.
10.Chief Complaint and Reason for Hospitalization - ANSWER Brief
description of the main symptoms leading to admission.
11.Past Medical History, Family History, and Social History - ANSWER
Summary of relevant history.
12.Hospital Course - ANSWER Details of diagnostic tests, procedures,
treatments, interventions, consultations, and any complications during the
stay.
13.Discharge Medications - ANSWER Comprehensive list of medications,
including changes, dosage, route, frequency, and indication.
14.Discharge Instructions - ANSWER Follow-up appointments, referrals,
specific instructions (wound care, diet, activity), and warning signs.
15.Discharge Disposition - ANSWER Patient's destination (home, skilled
nursing facility, etc.) and arrangements for services.
16.Signature and Date - ANSWER Of the healthcare provider completing the
summary.
17.Consultation Note - ANSWER Documents a request for an opinion or
advice from another healthcare provider or specialist regarding a specific
patient issue.
,18.ID - ANSWER Patient's name, age, gender, and code status (if inpatient).
19.Reason for Referral/Consult - ANSWER Clearly state why the consultation
was requested.
20.Outpatient - ANSWER Services provided without an overnight stay (e.g.,
clinic visits, same-day surgery).
21.Telehealth/Virtual - ANSWER Encounters conducted via video or phone,
billed under specific CMS guidelines.
22.CPT Codes - ANSWER Represent procedures and services rendered by
healthcare providers.
23.Category I CPT Codes - ANSWER Common services (e.g., 99214 for
outpatient E/M).
24.Category II CPT Codes - ANSWER Performance measurement codes
(optional).
25.Category III CPT Codes - ANSWER Emerging technologies.
26.ICD-10 Codes - ANSWER Used to document diagnoses and support
medical necessity.
27.Evaluation & Management (E/M) Codes - ANSWER Reflect complexity
and time of visit or care provided.
, 28.Level 1 Care - ANSWER Stable condition, minor treatment (e.g., office
visit).
29.Level 2-3 Care - ANSWER Acute illness, moderate complexity (e.g., chest
pain workup).
30.Level 4-5 Care - ANSWER Severe illness, potential for life-threatening
deterioration (e.g., ICU).
31.Hospital Levels - ANSWER SNF (Skilled Nursing Facility), IRF (Inpatient
Rehab Facility), LTAC (Long-Term Acute Care).
32.Role of the Hospitalist - ANSWER A provider who manages the care of
hospitalized patients.
33.Chief Complaint (CC) - ANSWER The primary reason the patient is
seeking care, ideally in their own words.
34.History of Present Illness (HPI) - ANSWER A chronological and detailed
narrative of the chief complaint.
35.Past Medical History (PMH) - ANSWER Significant medical conditions,
surgeries, hospitalizations, and treatments.
36.Medications - ANSWER Current medications, dosages, routes, and
frequencies, noting any discrepancies.
