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NR599 Final Exam 2024-2025. Questions and Correct Verified Answers. Graded A
Typology: Exams
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[Date]
3 key elements to medical decision making - ANSrisk data dx 6 contemporary Bioethical Standards - ANSAutonomy freedom veracity privacy beneficence fidelity 6 sections of cpt coding - ANSevaluation and management anesthesiology surgery radiology pathology medicine action / execution of tasks in a sequence is what - ANSworkflow
[Date] American Nurses Association- Code of Ethics for Nurses with Interpretive Statements. - ANSprovides specific guidance for ethical decision making and provides a valuable framework that can be used when working with HIT ANAs Code of Ethics for Nurses - ANS1. Respect for human dignity
[Date] clinical decision support systems - ANSa computer-based program designed to assist clinicians in making clinical decisions by filtering or integrating vast amounts of information and providing suggestions for clinical intervention Components of Risk Based E/M Coding - ANSHistory; Physical; Medical Decision Making computer aided translators - ANSusing technology to translate language or coding Computer applications designed to facilitate human decision-making processes. Usually are rule based, using a specified knowledge base and a set of rules to analyze data and information and provide recommendations to users ---- what is this - ANSclinical decision support system / CDS or CDSS Confidentiality - ANSThe act of holding information in confidence, not to be released to unauthorized individuals. CPT coding is maintained by - ANSAm med association CPT is a DRG (diagnosis related group) or MDC (major diagnosis codes) - ANSDRG - DRGs are more commonly associated with payment and reimbursement cybersecurity - ANS-Measures taken to protect a computer or computer system against unauthorized access or attack
[Date] Diagnosis-related groups (DRGs) - ANSSystem that categorizes into payment groups patients who are medically related with respect to diagnosis and treatment and statistically similar with regard to length of stay DRG vs MDC - ANSDRG- facilitates payment through prospective payment system MDC-organizes dx that affect similar physiological systems both primary purpose for billing E/m coding for each level of a new patient - ANSMinimal/RN visit- 99201 Problem focused- 99202 exp problem focused- 99203 detailed- 99204 comprehensive- 99205 E/m coding for each level of an established patient - ANSMinimal/RN visit- Problem focused- exp problem focused- detailed- comprehensive- each billing claim must contain what two things - ANSA CPT (procedural)code and ICD-10 (dx) code
[Date] Ethical Decision Making - ANS-Process that requires striking a balance between science and morality -Making informed choices about ethical dilemmas based on a set of standards differentiating right from wrong. Ethical Decision Making Process - ANS1. Identify the ethical dilemma
[Date] examples of mobile apps that the FDA intends to enforce discretion on - ANSapps that provide or facilitate supplemental clinical care, by coaching or prompting apps that provide patients with simple tools to organize and track their health information apps that provide easy access to information related to patients' health conditions or treatments apps marketed to help patients document, show, or communicate to providers potential medical conditions apps that perform simple calculations routinely used in clinical practice apps that enable individuals to interact with PHR systems or EHR apps that meet the definition of Medical Device Data Systems FDA oversight on medical devices contain - ANSoversees mobile apps that are medical devices and whose functionality could pose a risk to a patient's safety if the mobile app were to not function as intended. -Also oversee the cybersecurity management of these devices as well as the hospital network security. four most common types of PCS systems - ANSclinical documentation systems pharmacy information systems
[Date] laboratory information systems radiology information systems How can mHealth wearable devices reduce mortality rates - ANSwrist monitors that can monitor vital signs including respiratory rate, bp, hr, spo2, and temp which can send the info to an EHR which can calculate a wellness index based on the stats and a 0-5 scale (below 2.9 is good but above 3.0 is potentially bad) how is workflow analysis usually depicted - ANSvisually , in a process map how many levels of care are there for e/m coding and what are they - ANS Minimal/RN visit Problem focused exp problem focused detailed comprehensive Human information technologies (HIT) - ANShardware software integrated technologies are related licenses intellectual property upgrades or packaged solutions sold as services that are designed for or support the use by healthcare entities or patients for the electronic creation maintenance access or exchange of health information Human Technology Interface - ANSThe hardware and software through which the user interacts with any technology. for example computers patient monitors and
[Date] telephones. The human technology interface addresses the user's ability and the technologies functionality to complete the task demand. ICD 10 is maintained by - ANSworld health org issues having an ethical component includes the following - ANS1. Failure to adopt technology or use it adeptly
[Date] Major Diagnosis Category (MDC) - ANSorganize diagnosis that relate to similar physiological systems Maya, autodesk and Promodel are examples of - ANSworkplace analysis process mapping tools medical billing - ANSprocess of submitting claims to receive payment medical coding - ANScodes to communicate procedures performed and why Medical Decision Making (MDM) - ANSHealth care management process done after performing a history and physical examination on a patient that results in a plan of treatment. It is based on establishing one or more diagnosis and/or selecting a management or treatment option, amount of data or complexity of data reviewed, and complication and/or morbidity or mortality Medical Decision Making (MDM) in regards to E/M codes - ANS1 of 3 components to establishing E/M codes; way of quantifying the complexity of thinking that is required for the visit. medical devices - ANSAny equipment, instrument, implant, material, or apparatus used for the diagnosis, treatment, or monitoring of patients. mHealth - ANSgeneration, aggregation, and dissemination of health info via mobile and wireless devices
[Date] observation and documentation of workflow and how it can be altered is - ANSworkflow or process analysis patient-centered information systems - ANSpatient centered information systems focused on collecting data and disseminating information related to direct care POE/CPOE/CDS - ANSPOE- practitioner order entry, CPOE- computerized practitioner order entry, CDS- clinical decision support Privacy - ANSPractice of maintaining the security and confidentiality of patient records. Rational justification - ANSdeveloped through a logical process of decision making that gives proper attention to such things as facts, alternative perspectives, consequences to all stakeholders, and ethical principles. real time or synchronous applications - ANSall involved individuals are present for immediate exchange of information Reimbursement Coding - ANS-Claims and documentation filed by providers using medical diagnosis and procedure codes. -Assigned contingent upon data input from clinical team members based on a summative review of the clinical record by trained coders. Store and forward or asynchronous applications - ANSexchange prerecorded data between 2 or more individuals at different times
[Date] Telehealth - ANSuse of technology to deliver health care, health information, or health education (i.e. telephone, videophone, computer, store and forward imaging, streaming media, terrestrial and wireless communications) Telehealth tools - ANSCentral stations, web servers, and portals Peripheral biometric(medical) devices telephones videocameras personal emergency response systems sensor and activity monitoring medication management devices special needs telecommunications ready devices(preprogrammed infusion pumps, peak flow meters) telemedicine - ANSmedical information exchange from one site to another via electronic communications to improve patients health status Telemedicine applications types (2) - ANSStore-and-forward or asynchronous real-time or synchronous Three major questions must be asked when identifying an E/M code: - ANS1) Is the patient new or established?
[Date] Virtue Ethics Approach - ANSmoral behavior stems from personal virtues What is a CPT code? - ANSCurrent Procedural Technology (CPT) code represent treatments and procedures performed by a physician in a 5-digit format. for billing and reimbursement what is it called if workflow analysis is performed AFTER a new technology is implemented - ANSoptimization what is LOINC - ANSLogical Observation Identifiers, Names and Codes LOINC. , provides names and codes for laboratory test results and other observations. What is necessary for establishing E/M Codes - ANSPlace of Service; Type of Service; Patient Status What is SNOMED CT? - ANSSNOMED CT or SNOMED Clinical Terms is a systematically organized computer processable collection of medical terms providing codes, terms, synonyms, and definitions used in clinical documentation and reporting. what is the difference between expert systems and CDS systems - ANSexpert - not really used right now, systems that generate information / automatically intervene without requiring human action
[Date] CDS - guide clinicians to make choices, require clinician involvement What is the Husted bioethical decision making model centered on - ANShealthcare professionals implicit agreement with the patient What is the ICD10? - ANSalphanumeric coding for medical diagnosis / grouping like disease provides payer info on the necessity of the visit/procedure shorthand for dx what is the purpose of SNOMED and LIONC - ANSvocabulary used in more advanced / detailed coding systems what makes a medical app not a medical device - ANSApps that are not intended for use in the diagnosis of disease or other conditions, or in the cure, mitigation, treatment, or prevention of disease. What makes someone a new patient - ANShas not received service from a provider in the practice within 3 years who determines whether a mobile application is regulated for medical use - ANSFDA Who is the main regulatory agency of cybersecurity - ANSFDA
[Date] who regulates medical devices - ANSFDA Why do you need a cpt and an ICD code - ANSto determine reimbursement. if dx does not explain need for the procedure there is no payment