Exam (elaborations) NR 511 NR511 Final Exam Study Guide

1. Define diagnostic reasoning
Reflective thinking because the process involves questioning one's thinking to
determine 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 data?
What the patient tells you, complains of, etc.
Chief complaint
HPI
ROS
3. Discuss and 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 and 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
and why
6. What is 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.
7. What are CPT codes?
Common procedural terminology
Offers the official procedural coding rules and guidelines required when reporting
medical services and procedures performed by physician and non-physician providers.
8. What are ICD codes?
International classification of disease
Used to provide payer info on necessity of visit or procedure performed.
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.