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 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
, 2
2. Anesthesiology
3. Surgery
4. Radiology
5. Pathology
6. Medicine
International Classification of Diseases (ICD) system: we are in the tenth revision
of 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 that
corresponds.
6. Discuss how specificity, sensitivity & predictive value contribute to the usefulness
of 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% means
that 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 condition
is highly likely, a positive test result is more likely to be accurate. If a condition is very
unlikely, 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 choices
based on current research findings. Generally, EBP refers to using research findings
from 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, and
cultural considerations in the clinical decision-making process. Guidelines should be
followed 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 and
actions, research evidence, and clinical expertise
8. Discuss a minimum of three purposes of the written history and physical in
relation 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 information
should 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 the
care 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 corresponding
diagnosis code
Every procedure code needs a diagnosis to explain the necessity whether the code
represents an actual procedure performed or a nonprocedural encounter like an
office 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 from
the 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&M
code
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 thinking
that 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 most
complex
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 thumb
for 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 or
routine visits.
15. State the maximum number of hours that time can be spent “rounding” in a
facility
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 one
most 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 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
, 2
2. Anesthesiology
3. Surgery
4. Radiology
5. Pathology
6. Medicine
International Classification of Diseases (ICD) system: we are in the tenth revision
of 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 that
corresponds.
6. Discuss how specificity, sensitivity & predictive value contribute to the usefulness
of 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% means
that 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 condition
is highly likely, a positive test result is more likely to be accurate. If a condition is very
unlikely, 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 choices
based on current research findings. Generally, EBP refers to using research findings
from 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, and
cultural considerations in the clinical decision-making process. Guidelines should be
followed 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 and
actions, research evidence, and clinical expertise
8. Discuss a minimum of three purposes of the written history and physical in
relation 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 information
should 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 the
care 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 corresponding
diagnosis code
Every procedure code needs a diagnosis to explain the necessity whether the code
represents an actual procedure performed or a nonprocedural encounter like an
office 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 from
the 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&M
code
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 thinking
that 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 most
complex
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 thumb
for 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 or
routine visits.
15. State the maximum number of hours that time can be spent “rounding” in a
facility
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 one
most 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
