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Chamberlain College Of Nursing:NR 511 Week 1 Clinical Readiness Exam

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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 bei... ng drawn are based on evidence. Seen as a kind of critical thinking. 2. What is subjective data? What the patient tells you, complains of, etc. Chief complaint HPI ROS 3. What is objective data? What YOU can see, hear, or feel as part of your exam. Includes lab data, diagnostic test results. 4. Components of HPI Specifically related to the chief complaint only. Detailed breakdown of CC. OLDCART 5. Why must every procedure code have a corresponding diagnosis code? Diagnosis code explains the necessity of the procedure code. Insurance won't pay if they don't correspond. 6. What are the three components required in determining an outpatient office visit E&M code? Place of service Type of service Patient status 7. What is medical coding? The use of codes to communicate with payers about which procedures were performed and why 8. 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. 9. 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. 10. What are ICD codes? International classification of disease Used to provide payer info on necessity of visit or procedure performed. 11. 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. 12. What is sensitivity? Test that has few false negatives. Ability of a test to correctly identify a specific condition when it is present. The higher the sensitivity, the lesser the likelihood of a false negative. 13. What is predictive value? The likelihood that the patient actually has the condition and is, in part, dependent upon the prevalence of the condition in the population. If a condition is highly likely, the positive result would be more accurate. 14. What elements need to be considered when developing a plan? Pt's preferences and actions Research evidence Clinical state/circumstances Clinical expertise 15. What are the components of medical decision making in E&M coding? Risk Data Diagnosis The more time and consideration involved in dealing with a pt, the higher the reimbursement from the payer. Documentation must reflect MDM! 16. Correctly order the E&M office visit codes based on complexity from least to most complex. New patient: 1. Minimal/RN visit: 99201 2. Problem focused: 99202 3. Expanded problem focused: 99203 4. Detailed: 99204 5. Comprehensive: 99205 Established patient: 1. Minimal/RN visit: 99211 2. Problem focused: 99212 3. Expanded problem focused: 99213 4. Detailed: 99214 5. Comprehensive: 99215 17. Define the components of a SOAP note S: subjective (what the pt tells you) CC HPI PMH Fam Hx Social Hx ROS O: objective (what you can see, hear, feel on exam) Physical findings VS General survey HEENT Etc... A: assessment Global assessment of pt including differentials in order from most to least likely. Combination of subjective and objective info. List of dx addressed and billed for at the visit P: plan What you will Rx When to come back Diagnostic tests Pt education 18. What are purposes of the written H&P in relation to the importance of documentation? Important reference document that gives concise info about the pt's Hx and exam findings. Outlines a plan for addressing issues that prompted the visit. Info should be presented in a logical fashion that prominently features all data relevant to the pt's condition. Is a means of communicating info to all providers involved in the pt's care. Is a medical-legal document. Is essential in order to accurately code and bill for services. 19. When is a pt considered a "new" pt? If that pt has never been seen in that clinic or by that group of providers OR if the pt has not been seen in the past 3 years. 20. What does a well-rounded clinical experience mean? Includes seeing kids from birth through young adult visits for well child and acute visits, as well as adults for wellness or acute/routine visits. Seeing a variety of pt's, including 15% of peds and 15% of women's health of total time in the program. 21. What are the maximum number of hours that time can be spent "rounding" in a facility during clinicals? No more than 25% of total practicum hours in the program 22. What are 9 things that must be documented in the clinical encounter logs? Date of service Age Gender and ethnicity Visit E&M code CC Procedures Tests performed and ordered Dx Level of involvement (mostly student, mostly preceptor, together, etc.) 23. What is the first "S" in the SNAPPS presentation? Summarize: present the pt's H&P findings 24. What is the "N" in the SNAPPS presentation? Narrow: based on the H&P findings, narrow down to the top 2-3 differentials 25. What is the "A" in the SNAPPS presentation? Analyze: analyze the differentials. Compare and contrast H&P findings for each of the differentials and narrow it down to the most likely one 26. What is the first "P" in the SNAPPS presentation? Probe: ask the preceptor questions of anything you are unsure of. 27. What is the second "P" in the SNAPPS presentation? Plan: come up with a specific management plan. 28. What is the last "S" in the SNAPPS presentation? Self-directed learning: an opportunity to investigate more about any topics that you are uncertain of. 29. Drew Brees is scheduled for an acute visit for a skin lesion. After looking at his lesion he pulls out a long list of things he wants to discuss. You are 30 minutes behind on your schedule and you only have 15 minutes for this appointment. Which of the following is the best response to the patient? A. I see you have a list of concerns and I want to discuss them but my schedule will only allow for a few items today. Let's look at them together and identify the 3 most important items for you to discuss today. Then we can make a plan to address the remaining concerns for another visit. B. I'd really like to go over your concerns with you but you were only booked for an acute visit, which is a limited amount of time. I am already behind and I don't want to make the other patients who are waiting mad. Can you the front desk to schedule your next appointment for a longer time slot please? C. Wow that's quite a list. If you came in more regularly as I've recommended, you might not have all of these concerns. D. I wish I could address all of your issues this visit, but I'm already behind and my evaluation is based on productivity. A. I see you have a list of concerns and I want to discuss them but my schedule will only allow for a few items today. Let's look at them together and identify the 3 most important items for you to discuss today. Then we can make a plan to address the remaining concerns for another visit. 30. Which statement(s) regarding practice guidelines is (are) NOT true? a. They are flexible b. They should be utilized in every circumstance c. They provide a reference point for decision making d. All of the above They should be utilized in every circumstance 31. T/F A maximum of 20 alternative hours can be used as part of the 125 hour practicum requirement for each clinical course. True 32. The number of cases of a particular disease in a population at a given time is known as: a. Prevalence b. Risk c. Incidence d. Morbidity Incidence 33. Which of the following is required when documenting clinical experiences in your student clinical encounter log? a. E&M visit code (99202, etc.) b. Date of service c. Age d. All of the above All of the above 34. T/F New practitioners especially need support to develop confidence in their diagnostic and treatment-planning capabilities. True 35. Which of the following statement(s) is (are) true? a. Clinical logs are not legal documents b. You may make an amendment to your NR511 clinical log when you are in NR601 c. Clinical logs must demonstrate a well-rounded clinical experience by graduation d. All of the above Clinical logs must demonstrate a well-rounded clinical experience by graduation 36. Your pt presents with a sore throat x2 days. You suspect that he may have strep pharyngitis because his best friend had it last week. You do not have rapid antigen tests in your office, so you send a throat swab for culture. Which ICD-10 code should you use on the lab requisition? a. Rule out strep pharyngitis (no code) b. Streptococcal pharyngitis (J02.0) c. Chronic pharyngitis (J31.2) d. Acute pharyngitis, unspecified (J02.9) Acute pharyngitis, unspecified (J02.9) 37. Point of care strategy involves: a. Having readily available evidence-based resources b. Asking a clinical question c. Applying the findings to the individual pt d. All of the above All of the above 38. Which statement is true regarding SOAP notes? a. SOAP notes are a way to document an interaction between a pt and provider. b. SOAP notes become part of the pt's permanent record c. SOAP notes can serve as a means of communication between health care professionals d. All of the above All of the above 39. Which statement is true? a. The differential diagnosis is the final diagnosis determined for the visit. b. A problem list is a list of possible diagnoses for the pt's CC c. A differential is a list of plausible diagnoses that fit the presentation and findings of a pt c. The differential is ranked in order from least likely to most likely A differential is a list of plausible diagnoses that fit the presentation and findings of a pt 40. Which of the following statements regarding diagnostic reasoning is NOT true? a. Diagnostic reasoning involves using a person's intuition as the sole basis for decision making b. Diagnostic reasoning is hypothesis driven c. Diagnostic reasoning involves the recognition of clues and the analysis of clinical data d. Diagnostic reasoning involves developing conclusions based on research evidence Diagnostic reasoning involves using a person's intuition as the sole basis for decision making 41. T/F The level of Evaluation & Ma [Show More]

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