NR 511 Week 1 Study Guide, Definitions and Answers

Define diagnostic reasoning.
Identify subjective & objective data.
Identify the components of the HPI.
Develop an appropriate differential.
Describe the differences between medical billing and medical coding.
Compare and contrast the two coding classification systems that are currently used in the U.S. healthcare system.
Discuss how specificity, sensitivity, and predictive value contribute to the usefulness of diagnostic data.
Discuss the elements that need to be considered when developing a plan.
Describe the components of medical decision making in E&M coding.
Correctly order the E&M office visit codes based on complexity from least to most complex
Define the components of a SOAP note.
Discuss a minimum of three purposes of the written history and physical in relation to the importance of documentation.
Accurately document why every procedure code must have a corresponding diagnosis code.
Correctly identify a patient as new or established given the historical information.
Identify the three components required in determining an outpatient, office visit E&M code.
Describe the components of medical decision making in E&M coding.
Explain what a “well rounded” clinical experience means.
Discuss the maximum number of hours that time can … spent “rounding” in a facility.
Discuss nine things that must … documented when inputting data into clinical encounter logs.
Explain each part of the acronym the SNAPPS presentation.

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