NR 511 Final exam questions with complete and
accurate answers/graded A+
1.Define Diagnostic Reasoning: 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: reports, complaints of , replies to provider questions,
includes ROS, CC, HPI
3.Discuss and identify objective data: 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: 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: the use of codes to communicate with payers about which procedures
were performed and why
6.Medical billing: 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
7.2 Coding Classification systems that are currently used in the US healthcare system: 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: referring to the ability of the test to correctly detect a specific condition
9.Sensitivity: a test with a few false negatives
10.Predictive value: 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: acknowledge the list, negotiate what to cover,
be honest, make a follow up
12.Components of medical decision making (E&M) coding: 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-com- plexity=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: 99212-99214
,14.Discuss a minimum of three purposes of the written H&P in relation to the importance of
documentation: 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 presente
in a logical fashion that prominently features all data immedi- ately 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 correspond- ing diagnosis
code: every procedure code needs a diagnosis to explain the neces- sity 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 informa- tion: 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: 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: 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 th
past 3 year
established-has received professional care within 3 year
19.Explain what a well rounded clinical experience is: 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
20.What is the maximum number of hours that can be spent rounding in a facility: <25%
21.State 9 things that must be documented when inputting data into clinical encounters:
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: 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 gas- troenteritis:
viral: norovirus-adults
rotovirus-0-2yrs
accurate answers/graded A+
1.Define Diagnostic Reasoning: 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: reports, complaints of , replies to provider questions,
includes ROS, CC, HPI
3.Discuss and identify objective data: 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: 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: the use of codes to communicate with payers about which procedures
were performed and why
6.Medical billing: 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
7.2 Coding Classification systems that are currently used in the US healthcare system: 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: referring to the ability of the test to correctly detect a specific condition
9.Sensitivity: a test with a few false negatives
10.Predictive value: 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: acknowledge the list, negotiate what to cover,
be honest, make a follow up
12.Components of medical decision making (E&M) coding: 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-com- plexity=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: 99212-99214
,14.Discuss a minimum of three purposes of the written H&P in relation to the importance of
documentation: 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 presente
in a logical fashion that prominently features all data immedi- ately 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 correspond- ing diagnosis
code: every procedure code needs a diagnosis to explain the neces- sity 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 informa- tion: 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: 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: 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 th
past 3 year
established-has received professional care within 3 year
19.Explain what a well rounded clinical experience is: 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
20.What is the maximum number of hours that can be spent rounding in a facility: <25%
21.State 9 things that must be documented when inputting data into clinical encounters:
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: 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 gas- troenteritis:
viral: norovirus-adults
rotovirus-0-2yrs
