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National Library of Medicine (NLM) - ✔✔largest biomedical database, acute
care and skilled nursing facilities, using DRGs
Trauma registry - ✔✔database of severe injuries
data steward - ✔✔develops data definitions and models
Uniform Hospital Discharge Data Set (UHDDS) - ✔✔collects uniform data
elements from heath records of every inpatient. Standard for collecting
Medicare & Medicaid data, definitions are component of DRGs.
Uniform Ambulatory Care Data Set (UACDS) - ✔✔standardized data set for
ambulatory (outpatient) setting. Intent to improve data comparison across
different settings of healthcare. Not required.
Minimum Data Sets (MDS) - ✔✔Mandated standard assessment form used
to collect data on nursing home residents/long term care settings. Used to
develop care plans and placement at appropriate care level.
Outcome and Assessment Information Set (OASIS) - ✔✔A standard core
assessment data tool developed to measure the outcomes of adult patients
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, receiving home health services under the Medicare and Medicaid
programs. Used to determine when to discharge patient from home health
or transfer for other services.
Healthcare Effectiveness Data and Information Set (HEDIS) - ✔✔Standard
performance measures to collect administrative, claims and health record
review data. Includes patient outcomes and treatment processes, evaluates
success of treatment plans.
Data Elements for Emergency Department Systems (DEEDS) -
✔✔supports uniform collection of data for ER, reduces incompatibilities of
ER records. Incorporates national standards for electronic data exchange
ORYX - ✔✔Accreditation process that integrates performance
measurement data. Developed by the Joint Commission
IG Principles - ✔✔Accountability, Transparency, Integrity, Protection,
Compliance, Availability, Retention, Disposition
Accountability - ✔✔Member of senior leadership, or a person (CEO, CIO,
Sterring Comittee), shall oversee the IG program and delegate program
responsibility for information management to appropriate individuals.
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