NR511 / NR 511 Final Exam (Latest 2023 /
2024): Differential Diagnosis & Primary Care
Practicum - Chamberlain week 8
1). Define diagnostic reasoning
Ans: To solve problems, to promote health, and to screen for disease or illness. All
require a sensitivity to complex stories, to contextual factors, and to sense of probability
and uncertainty.
Can be seen as a kind of critical thinking.
2). Discuss and identify subjective data
Ans: reports, complaints of , replies to provider questions, includes ROS, CC, HPI
3). Discuss and identify objective data
Ans: what you can see, hear, or feel as part of a clinical exam. Also includes
laboratory data and test results.
4). Discuss and identify the components of and hpi
Ans: OLDCARTS
Onset of CC, Location of CC, Duration of CC, Characteristics of CC, Aggravating factors
of CC, Relieving factors of CC, Treatment of CC, Severity of CC
5). Medical coding
Ans: the use of codes to communicate with payers about which procedures were
performed and why
6). Medical billing
Ans: 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
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, 7). 2 coding classification systems that are currently used in the us healthcare system
Ans: CPT-recognized universally and provide logical means to be able to track
healthcare data, trends, and outcomes.
ICD-10-shorthand for the patient's diagnosis, which are used to provide the payer
information on the necessity of the visit or procedures performed.
8). Specificity
Ans: referring to the ability of the test to correctly detect a specific condition
9). Sensitivity
Ans: a test with a few false negatives
10). Predictive value
Ans: likelihood the patient actually has a condition and is in part dependent upon the
prevalence of the condition in the population
11). Elements needed when developing a plan
Ans: acknowledge the list, negotiate what to cover, be honest, make a follow up
12). Components of medical decision making (e&m) coding
Ans: history, physical, medical decision making E&M coding requires a medical
decision maker
a way of quantifying the complexity of the thinking that is required for the visit-
complexity=risk, data, diagnosis
MDM score gives credit for the excess work involved in management of a more complex
patient
13). Correctly order the e&m office visits based on complexity from least to most complex
Ans: 99212-99214
14).
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, Discuss a minimum of three purposes of the written h&p in relation to the importance of
documentation
Ans: Important reference document that gives concise information about a patient's
history and exam finding
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
Means of communicating information to all providers who are involved in the care of a
particular patient
Important medical-legal document
Essential in order to accurately code and bill for services
15). Accurately document why every procedure code must have a corresponding diagnosis
code
Ans: 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
16). Correctly identify a patient as a new patient given the historical information
Ans: one who has not received professional services from a provider from the same
group practice within the past 3 year.
17). Correctly identify a patient as an established patient given the historical information
Ans: one who has received professional service from a provider of the office within
the past 3 years
18). Identify the 3 components required in determining an outpatient, office visit e&m code
Ans: place of service-inpatient, outpatient
type of service-consultation, office visit, hospital admission
patient status-new-has not received professional service from a provider in the same
practice within the past 3 year
established-has received professional care within 3 year
19). Explain what a well rounded clinical experience is
Ans: Includes both children from birth through young adult visits for well child and
acute visits, as well as wellness, acute, and routine visits of adults
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, 20). What is the maximum number of hours that can be spent rounding in a facility
Ans: <25%
21). State 9 things that must be documented when inputting data into clinical encounters
Ans: Date of service, gender and ethnicity, tests performed or orderd, visit E&M code,
chief concerns, diagnosis, age, procedures, level of involvement
22). Identify and explain each part of the acronym snapps
Ans: S-summarize, N-narrow, A-analyze, P-probe, P-plan-S-self-directing learning
23). Identify the most common type of pathogen responsible for acute gastroenteritis
Ans: viral: norovirus-adults
rotovirus-0-2yrs
24). Assessing for prior antibiotic use is a critical part of the history in patients with presenting
with _______________ due to_________________
Ans: Diarrhea/CDiff
25). Irritable bowel syndrome
Ans: disorder of the bowel function not from anatomic abnormality--constipation,
diarrhea, bloating, urgency w/diarrhea
+s/s--result from disordered sensations or abnormal function of the small and large
bowel
NOT associated with serious medical conditions, IBD, CA
26). Inflammatory bowel disorder
Ans: chronic immunologic disease that manifests in intestinal inflammation
Ulcerative colitis
crohn's disease
27). Two common inflammatory bowel diseases
Ans: Ulcerative colitis-mucosal surface of the colon is inflamed and ultimately results
in frability, erosions, and bleeding--most common in recto-sigmoid colon. Can involve
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2024): Differential Diagnosis & Primary Care
Practicum - Chamberlain week 8
1). Define diagnostic reasoning
Ans: To solve problems, to promote health, and to screen for disease or illness. All
require a sensitivity to complex stories, to contextual factors, and to sense of probability
and uncertainty.
Can be seen as a kind of critical thinking.
2). Discuss and identify subjective data
Ans: reports, complaints of , replies to provider questions, includes ROS, CC, HPI
3). Discuss and identify objective data
Ans: what you can see, hear, or feel as part of a clinical exam. Also includes
laboratory data and test results.
4). Discuss and identify the components of and hpi
Ans: OLDCARTS
Onset of CC, Location of CC, Duration of CC, Characteristics of CC, Aggravating factors
of CC, Relieving factors of CC, Treatment of CC, Severity of CC
5). Medical coding
Ans: the use of codes to communicate with payers about which procedures were
performed and why
6). Medical billing
Ans: 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
PaperStoc.com Page 1 of 42
, 7). 2 coding classification systems that are currently used in the us healthcare system
Ans: CPT-recognized universally and provide logical means to be able to track
healthcare data, trends, and outcomes.
ICD-10-shorthand for the patient's diagnosis, which are used to provide the payer
information on the necessity of the visit or procedures performed.
8). Specificity
Ans: referring to the ability of the test to correctly detect a specific condition
9). Sensitivity
Ans: a test with a few false negatives
10). Predictive value
Ans: likelihood the patient actually has a condition and is in part dependent upon the
prevalence of the condition in the population
11). Elements needed when developing a plan
Ans: acknowledge the list, negotiate what to cover, be honest, make a follow up
12). Components of medical decision making (e&m) coding
Ans: history, physical, medical decision making E&M coding requires a medical
decision maker
a way of quantifying the complexity of the thinking that is required for the visit-
complexity=risk, data, diagnosis
MDM score gives credit for the excess work involved in management of a more complex
patient
13). Correctly order the e&m office visits based on complexity from least to most complex
Ans: 99212-99214
14).
PaperStoc.com Page 2 of 42
, Discuss a minimum of three purposes of the written h&p in relation to the importance of
documentation
Ans: Important reference document that gives concise information about a patient's
history and exam finding
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
Means of communicating information to all providers who are involved in the care of a
particular patient
Important medical-legal document
Essential in order to accurately code and bill for services
15). Accurately document why every procedure code must have a corresponding diagnosis
code
Ans: 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
16). Correctly identify a patient as a new patient given the historical information
Ans: one who has not received professional services from a provider from the same
group practice within the past 3 year.
17). Correctly identify a patient as an established patient given the historical information
Ans: one who has received professional service from a provider of the office within
the past 3 years
18). Identify the 3 components required in determining an outpatient, office visit e&m code
Ans: place of service-inpatient, outpatient
type of service-consultation, office visit, hospital admission
patient status-new-has not received professional service from a provider in the same
practice within the past 3 year
established-has received professional care within 3 year
19). Explain what a well rounded clinical experience is
Ans: Includes both children from birth through young adult visits for well child and
acute visits, as well as wellness, acute, and routine visits of adults
PaperStoc.com Page 3 of 42
, 20). What is the maximum number of hours that can be spent rounding in a facility
Ans: <25%
21). State 9 things that must be documented when inputting data into clinical encounters
Ans: Date of service, gender and ethnicity, tests performed or orderd, visit E&M code,
chief concerns, diagnosis, age, procedures, level of involvement
22). Identify and explain each part of the acronym snapps
Ans: S-summarize, N-narrow, A-analyze, P-probe, P-plan-S-self-directing learning
23). Identify the most common type of pathogen responsible for acute gastroenteritis
Ans: viral: norovirus-adults
rotovirus-0-2yrs
24). Assessing for prior antibiotic use is a critical part of the history in patients with presenting
with _______________ due to_________________
Ans: Diarrhea/CDiff
25). Irritable bowel syndrome
Ans: disorder of the bowel function not from anatomic abnormality--constipation,
diarrhea, bloating, urgency w/diarrhea
+s/s--result from disordered sensations or abnormal function of the small and large
bowel
NOT associated with serious medical conditions, IBD, CA
26). Inflammatory bowel disorder
Ans: chronic immunologic disease that manifests in intestinal inflammation
Ulcerative colitis
crohn's disease
27). Two common inflammatory bowel diseases
Ans: Ulcerative colitis-mucosal surface of the colon is inflamed and ultimately results
in frability, erosions, and bleeding--most common in recto-sigmoid colon. Can involve
PaperStoc.com Page 4 of 42
