1
NR511 Midterm Exam
Study Guide
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 eachnew
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; alsoincludes
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 ofwhether
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 bya healthcare
provider.
5. Compare and contrast the 2 coding classification systems that are currently usedin the US
healthcare system
• Common Procedural Terminology (CPT) system: offers the official procedural
coding rules and guidelines required when reporting medical services andprocedures
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 representedby a five-
digit code that is presented in six sections, including
1. Evaluation & Management
, 2
2. Anesthesiology
3. Surgery
4. Radiology
5. Pathology
6. Medicine
• International Classification of Diseases (ICD) system: we are in the tenth revisionof the
system, and, therefore, the classification system is known as ICD-10
➢ ICD-10 codes are shorthand for the patient’s diagnoses, which are used to provide
the payer information on the necessity of the visit or procedure performed. This
means that every CPT code must have a diagnosis code thatcorresponds.
6. Discuss how specificity, sensitivity & predictive value contribute to the usefulnessof the
diagnostic data
• When we describe the specificity of a test, we are referring to the ability of the test
to correctly detect a specific condition. If the patient has the condition but testing is
negative, we describe this as a false negative. If the patient does not have the condition but
the test result is positive, this is considered to be a false positive test.
• When a test is very sensitive, we mean it has few false negatives. The higher the
sensitivity, the lesser the likelihood of a false negative. A sensitivity of 99% meansthat it is
very unlikely for a false negative result.
• Predictive value is the likelihood that the patient actually has the condition and is, in
part, dependent upon the prevalence of the condition in the population. If a conditionis highly
likely, a positive test result is more likely to be accurate. If a condition is veryunlikely, a
positive test needs to be questioned and perhaps additional testing would need to be done.
• 5 things to consider before ordering a test: cost, convenience, sensitivity,
specificity, risk of missing a condition (predictive value)
7. Discuss the elements that need to be considered when developing a plan
• Evidence based care: providing care and making treatment and screening choicesbased on
current research findings. Generally, EBP refers to using research findingsfrom multiple
studies that are convincing enough that a consensus is formed recommending the findings be
used for clinical decision-making or practice guidelines.
• EBP also involves inclusion of patient and provider preferences, patient values, andcultural
considerations in the clinical decision-making process. Guidelines should befollowed in the
majority of cases unless there is a clear rationale for deviating from them to serve the
particular needs of the patient.
• Elements include clinical state and circumstances, patient’s preferences andactions,
research evidence, and clinical expertise
8. Discuss a minimum of three purposes of the written history and physical inrelation
to the importance of documentation
• It is an important reference document that gives concise information about a patient's
history and exam findings.
, 3
• It outlines a plan for addressing the issues that prompted the visit. This informationshould
be presented in a logical fashion that prominently features all data immediately relevant to
the patient's condition.
• It is a means of communicating information to all providers who are involved in thecare of
a particular patient.
• It is an important medical-legal document.
• It is essential in order to accurately code and bill for services.
9. Accurately document why every procedure code must have a correspondingdiagnosis
code
• Every procedure code needs a diagnosis to explain the necessity whether the code
represents an actual procedure performed or a nonprocedural encounter like anoffice visit.
• Understanding and accurately recording procedure and diagnosis codes are
necessities in order for you or your practice to get reimbursed.
10. Correctly identify a patient as new or established given the historical information
• A new patient is one who has not received professional service from a provider fromthe
same group practice within the past 3 years. Conversely, an established patient has received
professional service from a provider of your office within the last 3 years.
11. Identify the 3 components required in determining an outpatient, office visit E&Mcode
• Place of service
• Type of service
• Patient status
• 3 components in determining the E&M code are Hx, PE, & Medical Decision Making
12. Describe the components of Medical Decision Making in E&M coding
• Medical decision making is another way of quantifying the complexity of the thinkingthat is
required for the visit.
• Complexity of a visit is based on three criteria: risk, data, & diagnosis
• MDM score gives us credit for the excess work involved in management of a more
complex patient.
13. Correctly order the E&M office visit codes based on complexity from least to mostcomplex
New Established
Minimal/RN visit 99201 99211
Problem Focused 99202 99212
Exp. Problem Focused 99203 99213
Detailed 99204 99214
Comprehensive 99205 99215
14. Explain what a “well rounded” clinical experience means
, 4
• Both state boards of nursing and the National Certification Exam bodies can ask to audit your
clinical hours when you apply for testing and licensing. If they feel you don’t have a varied
enough experience across the lifespan, they can refuse to allow you to sit for your exam or be
licensed as a family nurse practitioner. (A rule of thumbfor them is 15% of peds and 15% of
women’s health exposure of total clinical time in a program.)
• A true well-rounded experience will include both children from birth through young
adult visits for well child and acute visits, as well as adults for wellness and acute orroutine
visits.
15. State the maximum number of hours that time can be spent “rounding” in afacility
• Time spent is no more than 25% of total practicum hours for that course.
16. State 9 things that must be documented when inputting data into clinical
encounter
1. Date of service
2. Age
3. Gender and ethnicity
4. Visit E&M code (e.g., 99203)
5. Chief concern
6. Procedures
7. Tests performed or ordered
8. Diagnoses
9. Level of involvement (mostly student, mostly preceptor, together, etc.).
17. Identify and explain each part of the acronym SNAPPS
• Summarize: present your patient’s history and physical exam findings
• Narrow: narrow your differential down to 2-3 differential diagnoses
• Analyze: analyze the differential. Compare and contrast the history and physical exam
findings for each of the differentials you have, ultimately coming down to onemost likely
diagnosis based on your data.
• Probe: ask the preceptor questions about things that you aren’t quite sure about.
• Plan: come up with a management plan, being as specific as possible.
• Self-directed learning: investigate more about the topics you are unsure about.
Week 2
• Pain in abdomen relative to quadrants
➢ LUQ: stomach ulcers, pancreatitis, and gastritis
➢ RUQ: problems with gallbladder, hepatitis, or pancreatitis
➢ RLQ: Inflammatory bowel disease (IBD), irritable bowel syndrome (IBS),
infectious colitis, and constipation
➢ LLQ: diverticulitis, inflammatory bowel disease (IBD), irritable bowel syndrome
(IBS), constipation, and infectious colitis
NR511 Midterm Exam
Study Guide
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 eachnew
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; alsoincludes
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 ofwhether
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 bya healthcare
provider.
5. Compare and contrast the 2 coding classification systems that are currently usedin the US
healthcare system
• Common Procedural Terminology (CPT) system: offers the official procedural
coding rules and guidelines required when reporting medical services andprocedures
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 representedby a five-
digit code that is presented in six sections, including
1. Evaluation & Management
, 2
2. Anesthesiology
3. Surgery
4. Radiology
5. Pathology
6. Medicine
• International Classification of Diseases (ICD) system: we are in the tenth revisionof the
system, and, therefore, the classification system is known as ICD-10
➢ ICD-10 codes are shorthand for the patient’s diagnoses, which are used to provide
the payer information on the necessity of the visit or procedure performed. This
means that every CPT code must have a diagnosis code thatcorresponds.
6. Discuss how specificity, sensitivity & predictive value contribute to the usefulnessof the
diagnostic data
• When we describe the specificity of a test, we are referring to the ability of the test
to correctly detect a specific condition. If the patient has the condition but testing is
negative, we describe this as a false negative. If the patient does not have the condition but
the test result is positive, this is considered to be a false positive test.
• When a test is very sensitive, we mean it has few false negatives. The higher the
sensitivity, the lesser the likelihood of a false negative. A sensitivity of 99% meansthat it is
very unlikely for a false negative result.
• Predictive value is the likelihood that the patient actually has the condition and is, in
part, dependent upon the prevalence of the condition in the population. If a conditionis highly
likely, a positive test result is more likely to be accurate. If a condition is veryunlikely, a
positive test needs to be questioned and perhaps additional testing would need to be done.
• 5 things to consider before ordering a test: cost, convenience, sensitivity,
specificity, risk of missing a condition (predictive value)
7. Discuss the elements that need to be considered when developing a plan
• Evidence based care: providing care and making treatment and screening choicesbased on
current research findings. Generally, EBP refers to using research findingsfrom multiple
studies that are convincing enough that a consensus is formed recommending the findings be
used for clinical decision-making or practice guidelines.
• EBP also involves inclusion of patient and provider preferences, patient values, andcultural
considerations in the clinical decision-making process. Guidelines should befollowed in the
majority of cases unless there is a clear rationale for deviating from them to serve the
particular needs of the patient.
• Elements include clinical state and circumstances, patient’s preferences andactions,
research evidence, and clinical expertise
8. Discuss a minimum of three purposes of the written history and physical inrelation
to the importance of documentation
• It is an important reference document that gives concise information about a patient's
history and exam findings.
, 3
• It outlines a plan for addressing the issues that prompted the visit. This informationshould
be presented in a logical fashion that prominently features all data immediately relevant to
the patient's condition.
• It is a means of communicating information to all providers who are involved in thecare of
a particular patient.
• It is an important medical-legal document.
• It is essential in order to accurately code and bill for services.
9. Accurately document why every procedure code must have a correspondingdiagnosis
code
• Every procedure code needs a diagnosis to explain the necessity whether the code
represents an actual procedure performed or a nonprocedural encounter like anoffice visit.
• Understanding and accurately recording procedure and diagnosis codes are
necessities in order for you or your practice to get reimbursed.
10. Correctly identify a patient as new or established given the historical information
• A new patient is one who has not received professional service from a provider fromthe
same group practice within the past 3 years. Conversely, an established patient has received
professional service from a provider of your office within the last 3 years.
11. Identify the 3 components required in determining an outpatient, office visit E&Mcode
• Place of service
• Type of service
• Patient status
• 3 components in determining the E&M code are Hx, PE, & Medical Decision Making
12. Describe the components of Medical Decision Making in E&M coding
• Medical decision making is another way of quantifying the complexity of the thinkingthat is
required for the visit.
• Complexity of a visit is based on three criteria: risk, data, & diagnosis
• MDM score gives us credit for the excess work involved in management of a more
complex patient.
13. Correctly order the E&M office visit codes based on complexity from least to mostcomplex
New Established
Minimal/RN visit 99201 99211
Problem Focused 99202 99212
Exp. Problem Focused 99203 99213
Detailed 99204 99214
Comprehensive 99205 99215
14. Explain what a “well rounded” clinical experience means
, 4
• Both state boards of nursing and the National Certification Exam bodies can ask to audit your
clinical hours when you apply for testing and licensing. If they feel you don’t have a varied
enough experience across the lifespan, they can refuse to allow you to sit for your exam or be
licensed as a family nurse practitioner. (A rule of thumbfor them is 15% of peds and 15% of
women’s health exposure of total clinical time in a program.)
• A true well-rounded experience will include both children from birth through young
adult visits for well child and acute visits, as well as adults for wellness and acute orroutine
visits.
15. State the maximum number of hours that time can be spent “rounding” in afacility
• Time spent is no more than 25% of total practicum hours for that course.
16. State 9 things that must be documented when inputting data into clinical
encounter
1. Date of service
2. Age
3. Gender and ethnicity
4. Visit E&M code (e.g., 99203)
5. Chief concern
6. Procedures
7. Tests performed or ordered
8. Diagnoses
9. Level of involvement (mostly student, mostly preceptor, together, etc.).
17. Identify and explain each part of the acronym SNAPPS
• Summarize: present your patient’s history and physical exam findings
• Narrow: narrow your differential down to 2-3 differential diagnoses
• Analyze: analyze the differential. Compare and contrast the history and physical exam
findings for each of the differentials you have, ultimately coming down to onemost likely
diagnosis based on your data.
• Probe: ask the preceptor questions about things that you aren’t quite sure about.
• Plan: come up with a management plan, being as specific as possible.
• Self-directed learning: investigate more about the topics you are unsure about.
Week 2
• Pain in abdomen relative to quadrants
➢ LUQ: stomach ulcers, pancreatitis, and gastritis
➢ RUQ: problems with gallbladder, hepatitis, or pancreatitis
➢ RLQ: Inflammatory bowel disease (IBD), irritable bowel syndrome (IBS),
infectious colitis, and constipation
➢ LLQ: diverticulitis, inflammatory bowel disease (IBD), irritable bowel syndrome
(IBS), constipation, and infectious colitis
