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| Question | Answer |
|---|---|
| Cultural competence | Ability to provide respectful, effective nursing care that meets patients’ cultural needs |
| Culturally competent nursing care | Care that respects patients’ beliefs, values, customs, language, and perspectives |
| Why cultural competence is important | Improves patient outcomes, trust, communication, and reduces health disparities |
| Cultural awareness | Self-examination of one’s own cultural beliefs, biases, and assumptions |
| Purpose of cultural awareness | Helps nurses recognize how personal bias may affect patient care |
| Cultural knowledge | Actively learning about different cultures, health beliefs, and practices |
| Cultural skill | Ability to collect culturally relevant data and perform culturally appropriate assessments |
| Cultural encounter | Direct interaction with patients from diverse cultural backgrounds |
| Benefit of cultural encounters | Reduces stereotyping and increases cultural understanding |
| Cultural desire | Genuine motivation to engage in the process of becoming culturally competent |
| Campinha-Bacote model | Framework describing cultural competence as an ongoing process with five components |
| Five components of cultural competence | Cultural awareness, knowledge, skill, encounter, and desire |
| Cultural sensitivity | Respecting and valuing cultural differences without judgment |
| Example of culturally competent care | Asking patients about cultural preferences rather than making assumptions |
| Communication in culturally competent care | Using interpreters, clear language, and awareness of nonverbal cues |
| Common barrier to cultural competence | Stereotyping or assuming all patients from a culture are the same |
| How nurses demonstrate respect for culture | Listening actively and incorporating patient beliefs into care plans |
| Outcome of culturally competent care | Increased patient satisfaction and improved health outcomes |
| Individualized cultural care | Treating each patient as a unique individual within their cultural context |
| E/M services | Evaluation and Management services used to bill for patient care visits |
| E/M services | Evaluation and Management services used to bill for patient care visits |
| Purpose of E/M coding | Ensures accurate reimbursement, legal compliance, and documentation |
| Three key components of E/M coding | History, Physical Exam, Medical Decision-Making (MDM) |
| Most important factor in E/M level selection | Medical Decision-Making (MDM) |
| CPT codes | Codes that describe what service was provided |
| ICD-10 codes | Codes that describe why the service was provided (diagnosis) |
| New patient definition | Patient not seen by same specialty within past 3 years |
| Established patient definition | Patient seen by same specialty within past 3 years |
| New patient office visit CPT codes | 99201–99205 |
| Established patient office visit CPT codes | 99211–99215 |
| Problem-focused history | 1–3 HPI elements |
| Expanded problem-focused history | 4–6 HPI elements plus limited ROS |
| Detailed history | Extended HPI, ROS, and at least one PFSH element |
| Comprehensive history | Complete HPI, ROS, and PFSH |
| Problem-focused physical exam | Examination of one system |
| Expanded physical exam | More than one system examined |
| Detailed physical exam | 6–7 organ systems examined |
| Comprehensive physical exam | 9 or more organ systems examined |
| Low complexity MDM | Stable problem, minimal data, minimal risk |
| Moderate complexity MDM | Chronic illness with adjustment, labs, or moderate risk |
| High complexity MDM | Life-threatening condition, extensive data, high risk |
| Examples of moderate complexity | Uncontrolled diabetes, asthma adjustment, depression meds |
| Examples of high complexity | Sepsis, MI, CHF with comorbidities, cancer diagnosis |
| Preventive visit purpose | Health promotion, screening, disease prevention |
| Diagnostic visit purpose | Evaluation and management of symptoms or conditions |
| Medicare Annual Wellness Visit CPT codes | G0438 (initial), G0439 (subsequent) |
| Welcome to Medicare visit CPT code | G0402 |
| Adult preventive visit CPT codes | 99381–99395 |
| Well-child visit CPT codes | 99381–99385 new, 99391–99395 established |
| Diagnostic visit CPT codes new patient | 99201–99205 |
| Diagnostic visit CPT codes established patient | 99211–99215 |
| Billing preventive and diagnostic same visit | Allowed with separate documentation |
| Modifier used when billing E/M and procedure together | Modifier 25 |
| Time-based coding rule | Used when >50% of visit spent counseling or coordination |
| What counts toward total time | Face-to-face and non-face-to-face work |
| Vaccination administration CPT codes | 90460 (<18 with counseling), 90471 (adult) |
| Incision and drainage CPT codes | 10060 simple, 10061 complicated |
| Skin excision CPT codes | 11400–11446 depending on lesion size |
| Co-morbidities effect on coding | Increase complexity if actively managed |
| Stable chronic condition coding level | Low complexity |
| Uncontrolled chronic condition coding level | Moderate complexity |
| Acute exacerbation with high risk coding | High complexity |
| Importance of documentation | Justifies code level and reimbursement |
| Purpose of ICD-10 coding | Accurate diagnosis, billing, compliance, data tracking |
| Example chronic ICD-10 code hypertension | I10 |
| Example chronic ICD-10 code diabetes | E11.9 |
| Example acute ICD-10 code chest pain | R07.9 |
| Key rule for E/M coding | Code what you manage and document |
| Diagnostic reasoning | Systematic process of collecting and analyzing data to reach a diagnosis |
| Primary goal of diagnostic reasoning | Accurate, timely diagnosis and improved patient outcomes |
| Key components of diagnostic reasoning | Data collection, problem identification, hypothesis generation, testing, decision-making |
| Main sources of diagnosis | Chart review and patient history |
| Percentage of diagnosis from history | Approximately 90% |
| Role of physical exam in diagnosis | Confirms or refines suspected diagnoses |
| Step 1 of diagnostic reasoning | Data collection |
| Data collection includes | CC, HPI, PMH, FH, SH, ROS, exam, diagnostics |
| Step 2 of diagnostic reasoning | Problem identification |
| Primary problem definition | Main reason patient seeks care |
| Secondary problem definition | Contributing or chronic conditions |
| Step 3 of diagnostic reasoning | Hypothesis generation |
| Differential diagnosis | Ranked list of possible causes of symptoms |
| VINDICATE framework | Vascular, Infectious, Neoplastic, Degenerative, Idiopathic, Congenital, Autoimmune, Traumatic, Endocrine |
| Step 4 of diagnostic reasoning | Hypothesis testing |
| Priority in hypothesis testing | Life-threatening conditions first |
| Step 5 of diagnostic reasoning | Clinical decision-making |
| Clinical decision-making includes | Diagnosis, management plan, follow-up |
| Anchoring bias | Fixating on initial diagnosis |
| Confirmation bias | Seeking evidence to support preferred diagnosis |
| Availability heuristic | Diagnosing based on recent experiences |
| How to reduce cognitive bias | Use systematic frameworks and reassess frequently |
| Purpose of differential diagnosis | Prevent misdiagnosis and improve accuracy |
| Pre-visit diagnostic thinking | Developing differential before seeing patient |
| Benefit of chart review | Increases efficiency and preparedness |
| Key factor in prioritizing differentials | Severity and likelihood |
| Can’t-miss diagnoses | Conditions that are fatal if untreated |
| History of present illness importance | Provides key diagnostic clues |
| Example HPI chest pain radiating left arm | Suggests myocardial infarction |
| Burning chest pain after meals | Suggests GERD |
| Sudden tearing chest pain to back | Suggests aortic dissection |
| Focused physical exam | Exam targeted to chief complaint |
| Use of diagnostics | Confirm or rule out prioritized diagnoses |
| Over-reliance on diagnostics risk | Can replace clinical judgment |
| Failure to reassess risk | Missed evolving diagnoses |
| Illness scripts | Pattern recognition based on known disease presentations |
| Clinical decision tools | HEART score, Wells score |
| Final diagnostic step | Confirm diagnosis and implement treatment plan |
| Key diagnostic reasoning takeaway | Prepare before entering the room |
Created by:
wyatt.karin