1. data dictionary A critical early step in designing an EHR is to develop a(n) in which th
characteristics of each data element are defined.
2. data sets One hospital discharge abstract systems were developed and their ability
provide comparative data to hospitals was established, it became necessar
to develop:
3. data sets Two purposes are served by : to identify data elements to be
collected about each pt & provide uniform data definitions.
4. UHDDS: The first resource that an HIT should consult when designing a data
Uniform collection form to collect data on pts in an acute-care hospital is:
Hospital Dis-
charge Data
Set The purpose of the is to list and define a set of common, uniform
data elements. The data elements are collected from the health
5. UHDDS:
records of every hospital inpt and later abstracted from the health record
Uniform
and included in national databases.
Hospital Dis-
charge Data
Set
6. Data set A is a list of recommended data elements with uniform
definitions that are relevant for a particular use. the contents of
vary by their purpose & are not meant to limit the number of data
elements that can be collected.
7. quantitative When deficiencies in the health record, such as reports that need to be
dictated or signed by a physician or other health professional, are
identified through
analysis, the record is filed in a specially designated area of the HIM
department, frequently called the incomplete file room.
8. Incomplet 9. MPI: Master Pa- tient Index
e record
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In a paper-based
system, the
completion of the
chart is monitored in
a special area of the
HIM department
called the
file room.
a list or database
created and
maintained by a
healthcare facility to
record the name and
identification number
of every pt who has
ever been admitted
or
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treated in the facility. While not listed as one of the core elements of
an , AHIMA recommends the use of a
Unique Patient Identifier to be included in the core data elements
of the .
10. Unit number filing system in which the pt receives a unique health record
number at the time of the first encounter. For all subsequent
encounters for a particular pt, the health record number that was
assigned for the first encounter is used
11. alphabetic The following are disadvantages of :
filing system Does not ensure a unique
identifier. Does not expand
evenly.
12. alphabetic Time consuming to purge or clean out files for inactive storage.
filing system
This system is usually satisfactory for a very small volume of records like that
of a small physician practice.
13. requisition a is a request from a clinical or other area in the organization to
charge out a specific health record. It may be in paper or electronic
form.
14. elements Usually includes the pt's name, health record number, date of the request,
of a date and time needed, name of the requester, and location for
requisition
delivery.
15. case mix index The average relative weight of all cases treated at a given facility or by a
given
physician which reflects the resource intensity or clinical severity of a
specific group in relation to the other groups in the classification
system: Sum of the # of cases in each DRG X weight for that DRG /
Total Cases
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