NR 511 MIDTERM STUDY GUIDE
1. Define diagnostic reasoning
Reflective thinking because thhe process involves questioning one's thinking to
determine if all possible avenues have been explored & if thhe conclusions that are
being drawn are based on evidence.
Seen as a kind of critical thinking.
2. What is subjective data?
Anything thhe patient tells you or complains of regarding thheir symptoms
Chief complaint
HPI
ROS
3. What is objective data?
Anything YOU can see, touch, feel, hear, or smell as part of your exam
Includes lab data, diagnostic test results, etc.
4. Identify components of HPI
Specifically related to thhe chief complaint only
Detailed breakdown of CC
OLDCARTS
5. Describe thhe differences between medical billing & medical coding.
Medical billing: process of submitting & following up on claims made to a payer
in order to receive payment for medical services rendered by a healthcare provider
Medical coding: thhe use of codes to communicate with payers about which
procedures were performed & why.
6. Compare & contrast thhe two coding classification systems that are
currently used in thhe US healthcare system.
ICD: International classification of disease codes are used to provide payer info on
necessity of visit or procedure performed. Shorth& for pt's dx.
,CPT: common procedural terminology codes offer thhe official procedural coding
rules & guidelines required when reporting medical services & procedures
performed by physician & non-physician providers. Must have corresponding ICD.
7. How do specificity, sensitivity, & predictive value contribute to thhe
usefulness of diagnostic data?
Specificity: ability of a test to correctly detect a specific condition. If a pt has a
condition but test is negative, it is a false negative. If pt does NOT have condition
but test is positive, it is false positive.
Sensitivity: test that has few false negatives. Ability of a test to correctly identify a
specific condition when it is present. Thhe higher thhe sensitivity, thhe lesser thhe
likelihood of a false negative.
Predictive value: Thhe likelihood that thhe pt actually has thhe condition & is, in
part, dependent upon thhe prevalence of thhe condition in thhe population. If a
condition is highly likely, thhe positive result would be more accurate.
Diagnostic tests can be used to confirm or rule out hypothheses.
Diagnostic tests may be used to screen for conditions.
Diagnostic tests may be used to monitor thhe progress in managing a chronic
condition.
8. Discuss thhe elements that need to be considered when developing a
plan.
Pt's preferences & actions
Research evidence
Clinical state/circumstances
Clinical expertise
9. Describe thhe components of medical decision making in E&M coding.
Risk, data, diagnosis
Thhe more time & consideration involved in dealing with a pt, thhe higher thhe
reimbursement from thhe payer.
Documentation must reflect MDM
, 10.Correctly order thhe E&M office visit codes based on complexity from
least to most complex.
New pt:
1. Minimal/RN visit: 99201
2. Problem focused: 99202
3. Exp&ed problem focused: 99203
4. Detailed: 99204
5. Comprehensive: 99205
Established pt:
1. Minimal/RN visit: 99211
2. Problem focused: 99212
3. Exp&ed problem focused: 99213
4. Detailed: 99214
5. Comprehensive: 99215
11.Thhe 5 key components of a comprehensive treatment plan are:
1. Diagnostics
2. Medication
3. Education
4. Referral/consultation
5. Follow-up planning
12.Define thhe components of a SOAP note.
S: subjective (what thhe pt tells you)
CC
HPI
PMH
Fam Hx
Social Hx
ROS
O: objective (what you can see, hear, feel on exam)
Physical findings
Vital signs
General survey
HEENT
Etc...
, A: assessment
Global assessment of pt including differentials in order from most to least likely
Combination of subjective & objective info
List of dx addressed & billed for at thhe visit
P: plan
What you will Rx
When to come back
Diagnostic tests
Pt education
13.Discuss minimum of three purposes of thhe written history & physical
in relation to thhe importance of documentation.
Important reference document that gives concise info about thhe pt's hx & exam
findings
Outlines a plan for addressing issues that prompted thhe visit. Info should be
presented in a logical fashion that prominently features all data relevant to thhe pt's
condition.
Is a means of communicating info to all providers involved in pt's care
Is a medical-legal document
Is essential in order to accurately code & bill for services
14.Why does every procedure code need a corresponding diagnosis code?
Diagnosis code explains thhe necessity of thhe procedure code.
Insurance won't pay if thhey don't correspond.
15.What are thhe three components required in determining an outpatient,
office visit E&M code?
Plan of service
Type of service
Patient status
16.Correctly ID a pt as a new or established given historical info.
Pt status: whethher or not pt is new or established.
New: has not received professional service from provider in same group within
1. Define diagnostic reasoning
Reflective thinking because thhe process involves questioning one's thinking to
determine if all possible avenues have been explored & if thhe conclusions that are
being drawn are based on evidence.
Seen as a kind of critical thinking.
2. What is subjective data?
Anything thhe patient tells you or complains of regarding thheir symptoms
Chief complaint
HPI
ROS
3. What is objective data?
Anything YOU can see, touch, feel, hear, or smell as part of your exam
Includes lab data, diagnostic test results, etc.
4. Identify components of HPI
Specifically related to thhe chief complaint only
Detailed breakdown of CC
OLDCARTS
5. Describe thhe differences between medical billing & medical coding.
Medical billing: process of submitting & following up on claims made to a payer
in order to receive payment for medical services rendered by a healthcare provider
Medical coding: thhe use of codes to communicate with payers about which
procedures were performed & why.
6. Compare & contrast thhe two coding classification systems that are
currently used in thhe US healthcare system.
ICD: International classification of disease codes are used to provide payer info on
necessity of visit or procedure performed. Shorth& for pt's dx.
,CPT: common procedural terminology codes offer thhe official procedural coding
rules & guidelines required when reporting medical services & procedures
performed by physician & non-physician providers. Must have corresponding ICD.
7. How do specificity, sensitivity, & predictive value contribute to thhe
usefulness of diagnostic data?
Specificity: ability of a test to correctly detect a specific condition. If a pt has a
condition but test is negative, it is a false negative. If pt does NOT have condition
but test is positive, it is false positive.
Sensitivity: test that has few false negatives. Ability of a test to correctly identify a
specific condition when it is present. Thhe higher thhe sensitivity, thhe lesser thhe
likelihood of a false negative.
Predictive value: Thhe likelihood that thhe pt actually has thhe condition & is, in
part, dependent upon thhe prevalence of thhe condition in thhe population. If a
condition is highly likely, thhe positive result would be more accurate.
Diagnostic tests can be used to confirm or rule out hypothheses.
Diagnostic tests may be used to screen for conditions.
Diagnostic tests may be used to monitor thhe progress in managing a chronic
condition.
8. Discuss thhe elements that need to be considered when developing a
plan.
Pt's preferences & actions
Research evidence
Clinical state/circumstances
Clinical expertise
9. Describe thhe components of medical decision making in E&M coding.
Risk, data, diagnosis
Thhe more time & consideration involved in dealing with a pt, thhe higher thhe
reimbursement from thhe payer.
Documentation must reflect MDM
, 10.Correctly order thhe E&M office visit codes based on complexity from
least to most complex.
New pt:
1. Minimal/RN visit: 99201
2. Problem focused: 99202
3. Exp&ed problem focused: 99203
4. Detailed: 99204
5. Comprehensive: 99205
Established pt:
1. Minimal/RN visit: 99211
2. Problem focused: 99212
3. Exp&ed problem focused: 99213
4. Detailed: 99214
5. Comprehensive: 99215
11.Thhe 5 key components of a comprehensive treatment plan are:
1. Diagnostics
2. Medication
3. Education
4. Referral/consultation
5. Follow-up planning
12.Define thhe components of a SOAP note.
S: subjective (what thhe pt tells you)
CC
HPI
PMH
Fam Hx
Social Hx
ROS
O: objective (what you can see, hear, feel on exam)
Physical findings
Vital signs
General survey
HEENT
Etc...
, A: assessment
Global assessment of pt including differentials in order from most to least likely
Combination of subjective & objective info
List of dx addressed & billed for at thhe visit
P: plan
What you will Rx
When to come back
Diagnostic tests
Pt education
13.Discuss minimum of three purposes of thhe written history & physical
in relation to thhe importance of documentation.
Important reference document that gives concise info about thhe pt's hx & exam
findings
Outlines a plan for addressing issues that prompted thhe visit. Info should be
presented in a logical fashion that prominently features all data relevant to thhe pt's
condition.
Is a means of communicating info to all providers involved in pt's care
Is a medical-legal document
Is essential in order to accurately code & bill for services
14.Why does every procedure code need a corresponding diagnosis code?
Diagnosis code explains thhe necessity of thhe procedure code.
Insurance won't pay if thhey don't correspond.
15.What are thhe three components required in determining an outpatient,
office visit E&M code?
Plan of service
Type of service
Patient status
16.Correctly ID a pt as a new or established given historical info.
Pt status: whethher or not pt is new or established.
New: has not received professional service from provider in same group within
