NR 511 Week 8 ASS Health Assessment Questions
with explained answers- University of British
Columbia
WEEK 1
1. Define diagnostic reasoning
Reflective thinking because the process involves questioning one's thinking to
determine if all possible avenues have been explored & if the conclusions that are
being drawn are based on evidence.
Seen as a kind of critical thinking.
2. Discuss & identify subjective
data? What the patient tells you, complains
of, etc. Chief complaint
HPI
ROS
3. Discuss & identify objective data?
What YOU can see, hear, or feel as part of your
exam. Includes lab data, diagnostic test results.
Components of HPI
4. Discuss & identify the components of
the HPI Specifically related to the chief complaint
only. Detailed breakdown of CC.
OLDCART
5. What is medical coding?
The use of codes to communicate with payers about which procedures were performed
& why
6. What is 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.
7. What are CPT codes?
Common procedural terminology
Offers the official procedural coding rules & guidelines required when reporting medical
services & procedures performed by physician & non-physician providers.
8. What are ICD codes?
International classification of disease
Used to provide payer info on necessity of visit or procedure performed.
NR 511 Week 8 ASS Health Assessment Questions
with explained answers- University of British
Columbia 1
,NR 511 Week 8 ASS Health Assessment Questions
with explained answers- University of British
Columbia
9. What is specificity?
The ability of the test to correctly detect a specific condition.
If a patient has a condition but test is negative, it is a false negative.
If a patient does NOT have a condition but the test is positive, it is a false positive.
10. What is sensitivity?
Test that has few false negatives.
Ability of a test to correctly identify a specific condition when it is
present. The higher the sensitivity, the lesser the likelihood of a false
negative.
11. What is predictive value?
The likelihood that the patient actually has the condition & is, in part, dependent upon
the prevalence of the condition in the population.
If a condition is highly likely, the positive result would be more accurate.
12. Discuss the elements that need to be considered when developing a
plan
Pt's preferences & actions
Research evidence
Clinical state/circumstances
Clinical expertise
13. Describe the components of Medical Decision Making in E&M coding
Risk
Data
Diagnosis
The more time & consideration involved in dealing with a pt, the higher the
reimbursement from the payer.
Documentation must reflect MDM!
evaluation & management (E&M)
14. Correctly order the E&M office visit codes based on complexity
from least to most complex
New patient: Established patient:
1. Minimal/RN visit: 99201 Minimal RN visit: 99211
2. Problem focused: 99202 Problem focused: 99212
3. Exp&ed problem focused: 99203 Exp&ed problem focused: 99213
4. Detailed: 99204 Detailed: 99214
5. Comprehensive: 99205 Comprehensive: 99215
15. Discuss a minimum of three purposes of the written history &
physical in relation to the importance of documentation
NR 511 Week 8 ASS Health Assessment Questions
with explained answers- University of British
Columbia 2
,NR 511 Week 8 ASS Health Assessment Questions
with explained answers- University of British
Columbia
Important reference document that gives concise info about the pt's Hx &
exam findings.
Outlines a plan for addressing issues that prompted the visit. Info should be presented
in a logical fashion that prominently features all data relevant to the pt's condition.
Is a means of communicating info to all providers involved in the pt's care.
Is a medical-legal document.
Is essential in order to accurately code & bill for services.
16. Accurately document why every procedure code must have a
corresponding diagnosis code
Diagnosis code explains the necessity of the procedure
code. Insurance won't pay if they don't correspond.
17. Correctly identify a patient as new or established given the
historical information If that pt has never been seen in that clinic or by that group of
providers OR if the pt has not been seen in the past 3 years.
18. Identify the 3 components required in determining an outpatient,
office visit E&M code
Place of service
Type of service
Patient status
19. Describe the components of Medical Decision Making in E&M coding
Risk
Data
Diagnosis
The more time & consideration involved in dealing with a pt, the higher the
reimbursement from the payer.
Documentation must reflect MDM!
evaluation & management (E&M)
20. Explain what a “well rounded” clinical experience means
Includes seeing kids from birth through young adult visits for well child & acute visits,
as well as adults for wellness or acute/routine visits.
Seeing a variety of pt's, including 15% of peds & 15% of women's health of total time in
the program.
21. State the maximum number of hours that time can be spent
“rounding” in a facility
No more than 25% of total practicum hours in the program
NR 511 Week 8 ASS Health Assessment Questions
with explained answers- University of British
Columbia 3
, NR 511 Week 8 ASS Health Assessment Questions
with explained answers- University of British
Columbia
22. State 9 things that must be documented when inputting
data into clinical encounter
Date of service
Age
Gender &
ethnicity Visit
E&M code CC
Procedures
Tests performed &
ordered Dx
Level of involvement (mostly student, mostly preceptor, together, etc.)
23. What is the first “S” in the SNAPPS presentation?
Summarize: present the pt's H&P findings
24. What is the “N” in the SNAPPS presentation?
Narrow: based on the H&P findings, narrow down to the top 2-3 differentials
25. What is the “A” in the SNAPPS presentation?
Analyze: analyze the differentials. Compare & contrast H&P findings for each of the
differentials & narrow it down to the most likely one
26. What is the first “P” in the SNAPPS presentation?
Probe: ask the preceptor questions of anything you are unsure of.
27. What is the second “P” in the SNAPPS presentation?
Plan: come up with a specific management plan
.
28. What is the last “S” in the SNAPPS presentation?
Self-directed learning: an opportunity to investigate more about any topics that you are
uncertain of.
WEEK 2
1. What is the most common type of pathogen responsible for acute
gastroenteritis?
Viral (can be viral, bacterial, or parasitic), usually norovirus
2. Assessing for prior antibiotic use is a critical part of the history
in patients presenting with diarrhea. True
3. Describe the difference between Irritable Bowel Disease (IBS) &
NR 511 Week 8 ASS Health Assessment Questions
with explained answers- University of British
Columbia 4
with explained answers- University of British
Columbia
WEEK 1
1. Define diagnostic reasoning
Reflective thinking because the process involves questioning one's thinking to
determine if all possible avenues have been explored & if the conclusions that are
being drawn are based on evidence.
Seen as a kind of critical thinking.
2. Discuss & identify subjective
data? What the patient tells you, complains
of, etc. Chief complaint
HPI
ROS
3. Discuss & identify objective data?
What YOU can see, hear, or feel as part of your
exam. Includes lab data, diagnostic test results.
Components of HPI
4. Discuss & identify the components of
the HPI Specifically related to the chief complaint
only. Detailed breakdown of CC.
OLDCART
5. What is medical coding?
The use of codes to communicate with payers about which procedures were performed
& why
6. What is 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.
7. What are CPT codes?
Common procedural terminology
Offers the official procedural coding rules & guidelines required when reporting medical
services & procedures performed by physician & non-physician providers.
8. What are ICD codes?
International classification of disease
Used to provide payer info on necessity of visit or procedure performed.
NR 511 Week 8 ASS Health Assessment Questions
with explained answers- University of British
Columbia 1
,NR 511 Week 8 ASS Health Assessment Questions
with explained answers- University of British
Columbia
9. What is specificity?
The ability of the test to correctly detect a specific condition.
If a patient has a condition but test is negative, it is a false negative.
If a patient does NOT have a condition but the test is positive, it is a false positive.
10. What is sensitivity?
Test that has few false negatives.
Ability of a test to correctly identify a specific condition when it is
present. The higher the sensitivity, the lesser the likelihood of a false
negative.
11. What is predictive value?
The likelihood that the patient actually has the condition & is, in part, dependent upon
the prevalence of the condition in the population.
If a condition is highly likely, the positive result would be more accurate.
12. Discuss the elements that need to be considered when developing a
plan
Pt's preferences & actions
Research evidence
Clinical state/circumstances
Clinical expertise
13. Describe the components of Medical Decision Making in E&M coding
Risk
Data
Diagnosis
The more time & consideration involved in dealing with a pt, the higher the
reimbursement from the payer.
Documentation must reflect MDM!
evaluation & management (E&M)
14. Correctly order the E&M office visit codes based on complexity
from least to most complex
New patient: Established patient:
1. Minimal/RN visit: 99201 Minimal RN visit: 99211
2. Problem focused: 99202 Problem focused: 99212
3. Exp&ed problem focused: 99203 Exp&ed problem focused: 99213
4. Detailed: 99204 Detailed: 99214
5. Comprehensive: 99205 Comprehensive: 99215
15. Discuss a minimum of three purposes of the written history &
physical in relation to the importance of documentation
NR 511 Week 8 ASS Health Assessment Questions
with explained answers- University of British
Columbia 2
,NR 511 Week 8 ASS Health Assessment Questions
with explained answers- University of British
Columbia
Important reference document that gives concise info about the pt's Hx &
exam findings.
Outlines a plan for addressing issues that prompted the visit. Info should be presented
in a logical fashion that prominently features all data relevant to the pt's condition.
Is a means of communicating info to all providers involved in the pt's care.
Is a medical-legal document.
Is essential in order to accurately code & bill for services.
16. Accurately document why every procedure code must have a
corresponding diagnosis code
Diagnosis code explains the necessity of the procedure
code. Insurance won't pay if they don't correspond.
17. Correctly identify a patient as new or established given the
historical information If that pt has never been seen in that clinic or by that group of
providers OR if the pt has not been seen in the past 3 years.
18. Identify the 3 components required in determining an outpatient,
office visit E&M code
Place of service
Type of service
Patient status
19. Describe the components of Medical Decision Making in E&M coding
Risk
Data
Diagnosis
The more time & consideration involved in dealing with a pt, the higher the
reimbursement from the payer.
Documentation must reflect MDM!
evaluation & management (E&M)
20. Explain what a “well rounded” clinical experience means
Includes seeing kids from birth through young adult visits for well child & acute visits,
as well as adults for wellness or acute/routine visits.
Seeing a variety of pt's, including 15% of peds & 15% of women's health of total time in
the program.
21. State the maximum number of hours that time can be spent
“rounding” in a facility
No more than 25% of total practicum hours in the program
NR 511 Week 8 ASS Health Assessment Questions
with explained answers- University of British
Columbia 3
, NR 511 Week 8 ASS Health Assessment Questions
with explained answers- University of British
Columbia
22. State 9 things that must be documented when inputting
data into clinical encounter
Date of service
Age
Gender &
ethnicity Visit
E&M code CC
Procedures
Tests performed &
ordered Dx
Level of involvement (mostly student, mostly preceptor, together, etc.)
23. What is the first “S” in the SNAPPS presentation?
Summarize: present the pt's H&P findings
24. What is the “N” in the SNAPPS presentation?
Narrow: based on the H&P findings, narrow down to the top 2-3 differentials
25. What is the “A” in the SNAPPS presentation?
Analyze: analyze the differentials. Compare & contrast H&P findings for each of the
differentials & narrow it down to the most likely one
26. What is the first “P” in the SNAPPS presentation?
Probe: ask the preceptor questions of anything you are unsure of.
27. What is the second “P” in the SNAPPS presentation?
Plan: come up with a specific management plan
.
28. What is the last “S” in the SNAPPS presentation?
Self-directed learning: an opportunity to investigate more about any topics that you are
uncertain of.
WEEK 2
1. What is the most common type of pathogen responsible for acute
gastroenteritis?
Viral (can be viral, bacterial, or parasitic), usually norovirus
2. Assessing for prior antibiotic use is a critical part of the history
in patients presenting with diarrhea. True
3. Describe the difference between Irritable Bowel Disease (IBS) &
NR 511 Week 8 ASS Health Assessment Questions
with explained answers- University of British
Columbia 4
