Chamberlain College of Nursing - NR 511Midterm Exam Study Guide

NR511 Midterm Exam Study Guide Week 1 1. Define diagnostic reasoning: type of critical thinking  Critical thinking involves the process of questioning one’s thinking to determine if all poss ible avenues have been explored and if the conclusions that are being drawn are based on evidence  Diagnostic reasoning then includes a systematic way of thinking that evaluates each new piece of data as it either supports some diagnostic hypothesis or reduces the likelihood of others. 2. Discuss and identify subjective & objective data  Subjective: what the patient reports; complaints of; tells you  Example: fevers, chills, lethargy, headache, blurred vision, ST, etc.  Is the “S” part of the SOAP note which includes the CC, HPI, & ROS  Objective: what you can see, hear, or feel as part of your clinical exam; also includes laboratory data and tests results  Example: thin, obese, normocephalic, rapid stress test +, etc.  Is the “O” part of the SOAP note 3. Discuss and identify the components of the HPI  Should be focused on the complaint and relevant symptoms  Detailed breakdown of the CC, written out as the OLDCARTS acronym  Onset, Location, Duration, Characteristics, Aggravating Factors, Relieving Factors, Treatments, Severity.  Duration: not referring to the onset of the symptom. Rather, it is an assessment of whether the symptom is constant or if it comes and goes.  Severity: level of pain, impact on work/school or ADLs. 4. Describe the differences between medical billing and medical coding