NR511 Final Exam
Study Guide
Week 1
1. Define diagnostic reasoning
a. Involves critical thinking in a way that evaluates new data to support the
hypothesis and reduce alternative hypothesis. This is done by evaluating all the
avenues to reach a conclusion that gives the best evidence to support the main
theory or hypothesis.
b. Examples of diagnostic reasoning are problem solving, health promotion, and
screening for disease or illness. All of these will require sensitivity, complexity,
contest, and a sense of probability and uncertainty.
2. Discuss and identify subjective & objective data
a. Subjective- what the patient reports as the CC and the responses to the
questions in the interview. Includes ROS, CC, and HPI
b. Objective – Information gained through exam, labs, imaging and other diagnostic
tests.
3. Discuss and identify the components of the HPI
a. Describes the reason the patient came in and include information using the
acronym OLDCARTS
i. Onset
ii. Location
iii. Duration
iv. Characteristics
v. Aggravating factors
vi. Relieving Factors
vii. Treatments tried
viii. Severity of the level of pain
4. Describe the differences between medical billing and medical coding
a. Medical billing 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.
b. Medical coding is the use of code to communicate with payers about the
procedures performed and why.
5. Compare and contrast the 2 coding classification systems that are currently used in the
US healthcare system – The two systems need to be in line i.e. the CPT code for the
activity performed should be followed with a relevant Diagnosis for the procedure
performed.
a. ICD 10- the newest version of shorthand for the patients diagnosis. It is
necessary for all diagnosis and procedures performed.
b. CPT- common procedural terminology represented by a 5 digit code that
provides a uniform language to describe medical, surgical, and diagnostic
services. Allows for tracking of treatments, trend and outcomes. Therer is 3 levels
of CPT codes: Category I- used in contemporary medical practice, Category II
-tracking codes used for new or performance measurement, and Category III-
Temporary coding used for new procedures, technology and services.
i. Catergory I has six sections
, 1. Evaluation and Management
2. Anesthesiology
3. Surgery
4. Radiology
5. Pathology
6. Medicine
6. Discuss how specificity, sensitivity & predictive value contribute to the usefulness of the
diagnostic data
a. Specificity of a test = greater when it has few false positives
no. of true negatives
specificity = -----------------------------
no. of all tested indiv, who do not have the dz
b. Sensitivity of a test = greater when it has few false negatives
no. of the true positives
sensitivity = --------------------------------
no. of tested indiv that have the dz
c. Predictive value = is in part dependent on the prevalence of the condition
true +
positive predictive value = -----------
all +
true -
Negative predictive value = ----------
all –
False positive - when a pt that does not have the condition has a positive
reading
False negative - when a pt that does have the condition but has a negative
reading
7. Discuss the elements that need to be considered when developing a plan
a. Diagnostic testing-what tests need to be conducted to clarify assessment
b. Education-specific problems being managed
c. Follow-up: when will the patient be seen again
d. Be honest
e. Negotiate what to cover
8. Describe the components of Medical Decision Making in E&M coding
a. There is three key components the determine risk-based E&M codes
i. History
ii. Physical
iii. Medical Decision Making- a way of quantifying the complexity of the
thinking that is required for the visit. And gives credit for the excess work
involved in management of a more complex patient.
1. Complexity of a visit is based on
a. Risk
b. Data
, c. diagnosis
b. Reason for consultation
c. HPI
d. ROS
e. Physical exam
f. Recommendation for testing and treatment
9. Correctly order the E&M office visit codes based on complexity from least to most
complex
a. New:
i. 99201 (minimal/RN visit)
ii. 992022 (Problem-focused)
iii. 99203 (Expanded problem- focused)
iv. 99204 (detailed)
v. 99215 (comprehensive)
b. Established:
i. 99211 (minimal/RN visit)
ii. 99212 (problem- focused)
iii. 99213 (expanded problem focused)
iv. 99214 (detailed)
v. 99215 (comprehensive)
10. Discuss a minimum of three purposes of the written history and physical in relation to the
importance of documentation
a. Provides documentation about the findings in the history and physical exam
b. Provides an outline for addressing the issues that prompted the visit.
c. Form of communication about care involved in patients.
d. Medical legal document
e. Essential for accurately coding and billing for services.
11. Accurately document why every procedure code must have a corresponding diagnosis
code
a. 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.
12. Correctly identify a patient as new or established given the historical information
a. New patient- who has not received services from the provider before or who has
not seen the provider/ group for over 3 years
b. Established patient- has been seen within the last 3 years,
13. Identify the 3 components required in determining an outpatient, office visit E&M code
a. Place of service
b. Type of Service
c. Patient status
14. Describe the components of Medical Decision Making in E&M coding
a. Risk
b. Data
c. Diagnosis
15. Correctly order the E&M office visit codes based on complexity from least to most
complex
a. New Pt: 99201 least complex -99205 most complex
, b. Established patient: 99211 least complex - 99215 most complex
16. Explain what a “well rounded” clinical experience means
a. Experience in a varied amount of paitnets across the lifespan
i. 15% pediatrics
ii. 15 % women’s health
17. State the maximum number of hours that time can be spent “rounding” in a facility
a. 25% of total practicum hours for that course
i. Rounding is permitted under the following circumstance
1. Your course instructor must be made aware that you’ll be rounding
2. The preceptor has facility privileges where the rounding will occur
3. Patients seen in a facility are patients of the provider’s outpatient
practice
4. The student actively participated in the patients care (no
observing)
18. State 9 things that must be documented when inputting data into clinical encounter
a. Date of service
b. Age
c. Gender and ethnicity
d. Visit E&M code
e. Chief concern
f. Procedures
g. Test performed or ordered
h. Diagnoses
i. Level of involvement
19. Identify and explain each part of the acronym SNAPPS
a. S = summarize - present the pt’s hx and physical exam findings
b. N = narrow - narrow your differential down - find the top 2-3 diagnosis
c. A = analyze - analyze the differential - compare and contrast the H&P +
physical exam findings for each of the dif that you have, coming down to 1
diagn.
d. P = probe - ask the preceptor questions about what you are not sure
e. P = plan - management plan, as specific as possible
f. S = self-directed learning - opportunity to investigate more about the topics
you are not sure
Week 2
1. Identify the most common type of pathogen responsible for acute gastroenteritis
a. Viral most common for adults
b. Rotavirus leading cause for children
c. Bacterial (30-80%)-
i. Campylobacter jejuni- most common in kids
ii. Salmenella- most common cause of food borne illness in US
2. Recognize that assessing for prior antibiotic use is a critical part of the history in patients
presenting with diarrhea
a. C-diff is common after use of fluoroquinolones and clindamycin
Study Guide
Week 1
1. Define diagnostic reasoning
a. Involves critical thinking in a way that evaluates new data to support the
hypothesis and reduce alternative hypothesis. This is done by evaluating all the
avenues to reach a conclusion that gives the best evidence to support the main
theory or hypothesis.
b. Examples of diagnostic reasoning are problem solving, health promotion, and
screening for disease or illness. All of these will require sensitivity, complexity,
contest, and a sense of probability and uncertainty.
2. Discuss and identify subjective & objective data
a. Subjective- what the patient reports as the CC and the responses to the
questions in the interview. Includes ROS, CC, and HPI
b. Objective – Information gained through exam, labs, imaging and other diagnostic
tests.
3. Discuss and identify the components of the HPI
a. Describes the reason the patient came in and include information using the
acronym OLDCARTS
i. Onset
ii. Location
iii. Duration
iv. Characteristics
v. Aggravating factors
vi. Relieving Factors
vii. Treatments tried
viii. Severity of the level of pain
4. Describe the differences between medical billing and medical coding
a. Medical billing 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.
b. Medical coding is the use of code to communicate with payers about the
procedures performed and why.
5. Compare and contrast the 2 coding classification systems that are currently used in the
US healthcare system – The two systems need to be in line i.e. the CPT code for the
activity performed should be followed with a relevant Diagnosis for the procedure
performed.
a. ICD 10- the newest version of shorthand for the patients diagnosis. It is
necessary for all diagnosis and procedures performed.
b. CPT- common procedural terminology represented by a 5 digit code that
provides a uniform language to describe medical, surgical, and diagnostic
services. Allows for tracking of treatments, trend and outcomes. Therer is 3 levels
of CPT codes: Category I- used in contemporary medical practice, Category II
-tracking codes used for new or performance measurement, and Category III-
Temporary coding used for new procedures, technology and services.
i. Catergory I has six sections
, 1. Evaluation and Management
2. Anesthesiology
3. Surgery
4. Radiology
5. Pathology
6. Medicine
6. Discuss how specificity, sensitivity & predictive value contribute to the usefulness of the
diagnostic data
a. Specificity of a test = greater when it has few false positives
no. of true negatives
specificity = -----------------------------
no. of all tested indiv, who do not have the dz
b. Sensitivity of a test = greater when it has few false negatives
no. of the true positives
sensitivity = --------------------------------
no. of tested indiv that have the dz
c. Predictive value = is in part dependent on the prevalence of the condition
true +
positive predictive value = -----------
all +
true -
Negative predictive value = ----------
all –
False positive - when a pt that does not have the condition has a positive
reading
False negative - when a pt that does have the condition but has a negative
reading
7. Discuss the elements that need to be considered when developing a plan
a. Diagnostic testing-what tests need to be conducted to clarify assessment
b. Education-specific problems being managed
c. Follow-up: when will the patient be seen again
d. Be honest
e. Negotiate what to cover
8. Describe the components of Medical Decision Making in E&M coding
a. There is three key components the determine risk-based E&M codes
i. History
ii. Physical
iii. Medical Decision Making- a way of quantifying the complexity of the
thinking that is required for the visit. And gives credit for the excess work
involved in management of a more complex patient.
1. Complexity of a visit is based on
a. Risk
b. Data
, c. diagnosis
b. Reason for consultation
c. HPI
d. ROS
e. Physical exam
f. Recommendation for testing and treatment
9. Correctly order the E&M office visit codes based on complexity from least to most
complex
a. New:
i. 99201 (minimal/RN visit)
ii. 992022 (Problem-focused)
iii. 99203 (Expanded problem- focused)
iv. 99204 (detailed)
v. 99215 (comprehensive)
b. Established:
i. 99211 (minimal/RN visit)
ii. 99212 (problem- focused)
iii. 99213 (expanded problem focused)
iv. 99214 (detailed)
v. 99215 (comprehensive)
10. Discuss a minimum of three purposes of the written history and physical in relation to the
importance of documentation
a. Provides documentation about the findings in the history and physical exam
b. Provides an outline for addressing the issues that prompted the visit.
c. Form of communication about care involved in patients.
d. Medical legal document
e. Essential for accurately coding and billing for services.
11. Accurately document why every procedure code must have a corresponding diagnosis
code
a. 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.
12. Correctly identify a patient as new or established given the historical information
a. New patient- who has not received services from the provider before or who has
not seen the provider/ group for over 3 years
b. Established patient- has been seen within the last 3 years,
13. Identify the 3 components required in determining an outpatient, office visit E&M code
a. Place of service
b. Type of Service
c. Patient status
14. Describe the components of Medical Decision Making in E&M coding
a. Risk
b. Data
c. Diagnosis
15. Correctly order the E&M office visit codes based on complexity from least to most
complex
a. New Pt: 99201 least complex -99205 most complex
, b. Established patient: 99211 least complex - 99215 most complex
16. Explain what a “well rounded” clinical experience means
a. Experience in a varied amount of paitnets across the lifespan
i. 15% pediatrics
ii. 15 % women’s health
17. State the maximum number of hours that time can be spent “rounding” in a facility
a. 25% of total practicum hours for that course
i. Rounding is permitted under the following circumstance
1. Your course instructor must be made aware that you’ll be rounding
2. The preceptor has facility privileges where the rounding will occur
3. Patients seen in a facility are patients of the provider’s outpatient
practice
4. The student actively participated in the patients care (no
observing)
18. State 9 things that must be documented when inputting data into clinical encounter
a. Date of service
b. Age
c. Gender and ethnicity
d. Visit E&M code
e. Chief concern
f. Procedures
g. Test performed or ordered
h. Diagnoses
i. Level of involvement
19. Identify and explain each part of the acronym SNAPPS
a. S = summarize - present the pt’s hx and physical exam findings
b. N = narrow - narrow your differential down - find the top 2-3 diagnosis
c. A = analyze - analyze the differential - compare and contrast the H&P +
physical exam findings for each of the dif that you have, coming down to 1
diagn.
d. P = probe - ask the preceptor questions about what you are not sure
e. P = plan - management plan, as specific as possible
f. S = self-directed learning - opportunity to investigate more about the topics
you are not sure
Week 2
1. Identify the most common type of pathogen responsible for acute gastroenteritis
a. Viral most common for adults
b. Rotavirus leading cause for children
c. Bacterial (30-80%)-
i. Campylobacter jejuni- most common in kids
ii. Salmenella- most common cause of food borne illness in US
2. Recognize that assessing for prior antibiotic use is a critical part of the history in patients
presenting with diarrhea
a. C-diff is common after use of fluoroquinolones and clindamycin
