NR 511 Week 1 Study Guide

• 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.