NR511 Midterm Exam Study Guide

1. Define Diagnostic Reasoning:Diagnostic reasoning is a critical thinking process used by healthcare providers to assess and interpret patient information in order to make accurate clinical decisions. It involves systematically gathering both subjective and objective data, analyzing the information, formulating potential diagnoses (differential diagnoses), and ultimately identifying the most probable diagnosis based on the evidence. This method ensures that patients receive timely and appropriate care tailored to their specific conditions.

2. Discuss and Identify Subjective & Objective Data:

• Subjective Data: This type of data is the information that patients provide about their experiences, symptoms, and feelings. It includes the patient’s own descriptions of what they are going through, such as their perception of pain, fatigue, dizziness, or other symptoms. Subjective data is personal and cannot be measured or observed directly by the healthcare provider.
• Objective Data: In contrast, objective data is information that can be measured, observed, or verified by the healthcare provider. It includes findings from physical examinations, diagnostic tests, and laboratory results, such as blood pressure readings, temperature, heart rate, imaging results, or physical signs like swelling, bruising, or abnormal heart sounds. Objective data provides concrete evidence to support clinical decision-making.

3. Discuss and Identify the Components of the HPI:The History of Present Illness (HPI) is a detailed narrative that describes the patient’s current medical concerns, including the onset and progression of symptoms. The HPI helps the healthcare provider understand the context and severity of the patient’s condition. Key components of the HPI include:

• Location: Where the symptom is felt in the body (e.g., chest, abdomen).
• Quality: The nature of the symptom (e.g., sharp, dull, throbbing).
• Severity: How intense the symptom is, often rated on a scale from 1 to 10.
• Duration: How long the symptom has been present (e.g., hours, days, weeks).
• Timing: The frequency and timing of the symptom (e.g., intermittent, constant, worse at night).
• Context: The situation or events that may have triggered or are associated with the symptom (e.g., after meals, during exercise).
• Modifying Factors: What makes the symptom better or worse (e.g., resting, taking medication).
• Associated Signs and Symptoms: Other symptoms that occur along with the primary complaint (e.g., fever, nausea, vomiting).

4. Describe the Differences Between Medical Billing and Medical Coding:

• Medical Billing: This process involves creating and submitting claims to insurance companies to obtain payment for healthcare services provided. Medical billers translate the medical codes provided by coders into insurance claims and ensure that healthcare providers receive appropriate reimbursement. Billers also track claims, manage patient billing inquiries, and handle denials and appeals.
• Medical Coding: Medical coding is the process of converting healthcare diagnoses, procedures, services, and equipment into standardized codes. These codes are used in the billing process to describe what services were provided to the patient and why. Coders assign specific codes based on the provider’s documentation, which are then used by billers to create insurance claims.

5. Compare and Contrast the Two Coding Classification Systems Currently Used in the US Healthcare System:

• Current Procedural Terminology (CPT) Codes: CPT codes are used to describe the medical, surgical, and diagnostic services provided by healthcare professionals. These codes are essential for billing and reimbursement, as they specify the exact procedures and services that were performed. CPT codes are categorized into sections such as Evaluation & Management (E&M), Anesthesiology, Surgery, Radiology, Pathology, and Medicine. Each code corresponds to a specific procedure, making it easier for insurance companies to understand the services provided.
• International Classification of Diseases (ICD) Codes: The ICD system, currently in its 10th revision (ICD-10), is a globally recognized system used to code and classify diseases, symptoms, and procedures. In the US, ICD-10 codes are used to document patient diagnoses and explain the medical necessity of services provided. Each CPT code submitted for reimbursement must be paired with a corresponding ICD-10 code to justify the treatment or procedure performed. This system ensures that healthcare providers are compensated for medically necessary services while maintaining consistency in medical record-keeping and data analysis.

These concepts are foundational to understanding the roles of diagnostic reasoning, data collection, medical billing, and coding in the healthcare setting. Mastery of these topics is essential for success in the NR511 course and for providing high-quality patient care.