1. Define diagnostic reasoning
Reflective thinking because thhe process involves questioning one's thinking to determine if all possible avenues have
... [Show More] been explored & if thhe conclusions that are being drawn are based on evidence.
Seen as a kind of critical thinking.
2. What is subjective data?
Anything thhe patient tells you or complains of regarding thheir symptoms
Chief complaint HPI
ROS
3. What is objective data?
Anything YOU can see, touch, feel, hear, or smell as part of your exam Includes lab data, diagnostic test results, etc.
4. Identify components of HPI
Specifically related to thhe chief complaint only Detailed breakdown of CC
OLDCARTS
5. Describe thhe differences between medical billing & medical coding. Medical billing: process of submitting & following up on claims made to a payer in order to receive payment for medical services rendered by a healthcare provider
Medical coding: thhe use of codes to communicate with payers about which procedures were performed & why.
6. Compare & contrast thhe two coding classification systems that are currently used in thhe US healthcare system.
ICD: International classification of disease codes are used to provide payer info on necessity of visit or procedure performed. Shorth& for pt's dx.
CPT: common procedural terminology codes offer thhe official procedural coding rules & guidelines required when reporting medical services & procedures performed by physician & non-physician providers. Must have corresponding ICD.
7. How do specificity, sensitivity, & predictive value contribute to thhe usefulness of diagnostic data?
Specificity: ability of a test to correctly detect a specific condition. If a pt has a condition but test is negative, it is a false negative. If pt does NOT have condition but test is
positive, it is false positive.
Sensitivity: test that has few false negatives. Ability of a test to correctly identify a specific condition when it is present. Thhe higher thhe sensitivity, thhe lesser thhe likelihood of a false negative.
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