Chamberlain College of Nursing NR511_Midterm_Exam

Week 1 1. Define diagnostic reasoning Reflective thinking because the process involves questioning one’s thinking to determining if all possible avenues have been explored and if the conclusions that are being drawn are based on evidence. *Seen as a kind of critical thinking. 2. Discuss and identify subjective & objective data - Subjective: What the pt tells you, complains of, etc. *Chief complaint, HPI, ROS - Objective: What YOU can see, hear, or feel as part of your exam. *lab, data, dx test results. 3. Discuss and identify the components of the HPI Specifically related to the CC only. Detailed breakdown of CC. OLDCART. 4. Describe the differences between medical billing and medical coding - Medical coding: The use of codes to communicate with payers about which procedures were performed and why - Medical billing: 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