Week 1
1. Define diagnostic reasoning
a. Involves critical thinking in a way that evaluates new data to support the
hypothesis and reduce alternative hypothesis. This is done by evaluating all the
avenues to reach a conclusion that gives the best evidence to support the main
theory or hypothesis.
b. Examples of diagnostic reasoning are problem solving, health promotion, and
screening for disease or illness. All of these will require sensitivity, complexity,
contest, and a sense of probability and uncertainty.
2. Discuss and identify subjective & objective data
a. Subjective- what the patient reports as the CC and the responses to the
questions in the interview. Includes ROS, CC, and HPI
b. Objective – Information gained through exam, labs, imaging and other diagnostic
tests.
3. Discuss and identify the components of the HPI
a. Describes the reason the patient came in and include information using the
acronym OLDCARTS
i. Onset
ii. Location
iii. Duration
iv. Characteristics
v. Aggravating factors
vi. Relieving Factors
vii. Treatments tried
viii. Severity of the level of pain
4. Describe the differences between medical billing and medical coding
a. Medical billing is the 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.
b. Medical coding is the use of code to communicate with payers about the
procedures performed and why.
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