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Ch4 Hlth Info Mngmt

Health Data Concepts

centerpiece of the the health care decision making process patient record
data collected/combined from many different sources aggregate data
aggregate data contains essential data/info to answer key questions of patient care, related to the who, what, when, where, why, and how
used for participation, monitoring care, document services received, proof of identity/ disability & verified billed services medical data
support or promotion of something advocacy
taken an advocacy position in promoting understanding of PHR through MyPHR consumer ed courses & website AHIMA
individual licensed/certified to deliver care to patients practitioner
physicians, nurses, & other clinicians treating a patient, use records as primary means of communication
practitioner(s) at follow-up facility/agency use record for continuing care
nursing staff in residential facility use data for care plans outlining nursing interventions
health record collects that data that documents provisions of service
use data to evaluate care, monitor use of resources, & receive payment for services rendered providers
analyze financial & case mic data for business planning & marketing activities administrators
are the basis of claims processing to pay for health care services provided data
include private insurance co., MCOs, & fiscal intermediaries (FIs) who process claims for Medicare & Medicaid third-party payers
are currently the basis for reporting & managing costs of care billing data
organizational resources including supplies, equipment, services, & providers can be taken into consideration in utilization review
case management facets of admission, continued stay, & discharge from an inpatient facility & day-to-day management of specific chronic problems have existing criteria
use data as basis for analysis, study, & evaluation of quality of care given to the patient quality assessments & improvement committees
uses secondary health care data to ensure that only qualified physicians practice medicine National Physician Data Bank
recent studies by IOM have increased focus on patient safety
review patient records to provide public assurance that quality health care is being provided accrediting, licensing, & certifying agencies
data serves as evidence in assessing compliance with standards of care
data serves as evidence in accrediting various HCOs
reviews of governmental financial resources are done on a continuing & retrospective basis
public health is concerned with threats to overall health of a community on the basis of population-based health care data analysis
focuses on treatment of individual medical health care
public health departments & programs, established by all levels of government, which include surveillance/control of infectious diseases, prevention/vaccination programs, & promote health behaviors
used to evaluate & assess job-related conditions/injuries & determine occupational hazards in workplace health care data
health data is used by employers to select HCOs, evaluate quality & manage costs
use as documentary evidence of patient's course of treatment to protect legal interests of all parties involved in patient health care attorneys & courts in judicial process
data may aid in determining the for admission of ___ ___ for treatment mentally ill
use info related to vital statistics, disease incidence & prevalence, report of child/elder abuse, etc. to provide aggregate data for public policy development
data is used by HCOs to support need for continuing & addition of services
assists educators/trainers in tying theory learned to practical aspects of care data documentation
significant aspect of improvement of care & assessment of effectiveness of treatment & improved methods for future care clinical research
help with early disease detection epidemiologists
report data that public needs to know, i.e. health hazards, diseases affecting public health & new developments in medical research media reporters
used in everyday care setting, data in PRs are essential resource for clinical & administrative decisions
effective decision making proceeds through the following steps: identify problem, data collection, develop alternatives, select best alternative, action, follow-up evaluation
data collection has significant impact on ___ & ___ of decision-making process efficiency & effectiveness
___ & ___ data enhance likelihood of effective decision, but do not guarantee it well-defined & accurately collected
must carefully consider purpose for data collection while gathering sufficient data items, but no more than required HIM Professional
staff time for entry/review, management & computer time/storage associated with data collection are a significant cost
satisfy an identified need for retention, retrieval, & use of data to generate meaningful information only reason to collect data
aid in facilitating data exchange & reducing misunderstandings definitions of data elements
word is plural & used whenever more than one element is described data
describes a single data element datum
data processed into meaningful form; adding to representation, telling recipient something not known before information
collects data & generates a report, either on paper or electronically; "repository of information" patient health record
health record is a more comprehensive term that includes prevention & screening data
more typically refers to encounters related to illness medical record
record that is used by practitioners while providing care services to review patient data or document own actions, observations, or instructions primary patient record
subset derived from primary patient record contains selected data elements, helping clinician/nonclinician in supporting evaluating & advancing patient care secondary patient record
refers to administration, regulation & payment functions patient care support
refers to quality assurance, utilization review & medical/legal audits patient care evaluation
refers to research patient care advancement
comprehensive patient record complied & accessible over patient's life span, from birth to death longitudinal patient record
has lead the way in creating longitudinal electronic patient records to serve their patient population VA
a combination of discrete data elements & narrative in various media current patient health record
collection, analysis, & dissemination of health-related info are crucial aspects, in addition to national leadership of health data standards & information privacy policy DHHS
coordinates all health/nonhealth data collection & analysis activities of the department DHHS Data Council
statutory public advisory body to DHHS on health data, statistics, & national health info policy National Committee on Vital & Health Statistics (NCVHS)
NCVHS also advises DHHS on HIPPA implementation
part of CDC of the DHHS and is federal government's principal vital health & statistics agency National Center for Health Statistics (NCHS)
data provided by NCHS are used by policy makers, Congress, administration, medical researcher
NVCHS leading government agency in standardization of health info, through uniform data sets
group of data items/elements & their definitions; often defined values for each data element data set
data set that has defined values for each element is useful for systematic data collection & measurement
formally made public, most frequently used in relationship to act of formally, publicly declaring new statutory/administrative law when it received final approval promulgated
data sets promulgated by NCVHS have influenced claim forms on which Medicare/Medicaid data sets are based and Conditions of Participation
uniform specification for data encountered into hospital ED records. DEEDS - Data Elements for Emergency Department Systems
comprehensive functional assessment of long-term care patients MDS - Minimum Data Set for Long-Term Care
core items of comprehensive assessment for adult home care patients; forms basis for measuring patient outcomes OASIS - Outcome and Assessment Information Set
improve ability to compare data in ambulatory care settings UACDS - Uniform Ambulatory Care Data Set
uniform collection of data on in patients; used by federal/state agencies UHDDS - Uniform Hospital Discharge Data Set
intended to describe minimal data about patients, resident, or clients DEEDS, MDS, OASIS, UACDS, UHDDS
currently hampered by inability to link data sets from various sources performance monitoring & outcomes
vitally important in managed care field, in order to follow patients through continuum of care and at multiple sites standardized data elements
info may not have to be collected at each encounter first 12 core health data elements
the only (1) of the first 12 core health data elements, which would need to be collected at each encounter unique identifier #1
CDC initiative that promotes use of data & info standards to advance development of efficient, integrated, & interoperable public health surveillance systems at state, local & federal levels Electronic Disease Surveillance System NEDSS
continuing, automatic capture & analysis of data that are already available electronically primary goal of NEDSS
reduce review by state/federal gov. & may facilitate payment for services, assuring consumers/payers of high quality of care reasons for accreditation
source for info about quality of nation's MCOs National Committee for Quality Assurance NCQA
to measure performance the NCQA uses Health Plan Employer Data & Information Set HEDIS
"Practice Briefs" are AHIMA's professional practice guidelines
present best practices & excellent for personal continuing education & evaluation of present organizational practices "Practice Briefs"
focuses of optimal use of health care IT & management systems for the betterment of human health Healthcare Information and Management Systems Society HIMSS
provides leadership in developments & implementation of information systems to improve patient care American Medical Informatics Association AMIA
research-based management data set that includes 17 across-settings elements Nursing Management Minimum Data Set NMMDS
understanding rules, standards & regulations is a solid foundation for developing a high quality health record
essential to consider specialized needs of all users of the record
ensures computer views/screens & paper forms are designed to facilitate collection of data elements as care is provided understanding flow of data & information
responsibility to identify who may provide care & then document that care in patient record health care organization
"any individual permitted by law & by the organization to provide care, treatment, & services without direction or supervision" licensed independent practitioner (LIP)
all forms and views, including all sides & segments of multipart paper forms & all screens of computer views must identify the patient
assigned to link patient to their record(s); used on all record forms/views to collect all patient data in correct record to be accessed by computer database query unique identifier number
the patient name and number are contained in a database called the master patient index (MPI)
index that identifies all patients who have been treated by facility & lists the number associated with the name master patient index (MPI)
master patient index (MPI) can be maintained manual,y or as part of a computerized system
data collect before care rendered to include sufficient info to identify patient positively along with basic patient clinical data registration record
registration record is one of the most commonly computerized forms
personal data elements, sufficient to identify patient, collected from patient/patient's rep & not related to health status or services provided demographics
identification sheet, face sheet, or admission-discharge record, are all names associated with the registration record
body of form contains statement indicating patient agrees to receive basic, routine services, diagnostic procedures & medical care; in addition to statement explaining outcomes cannot be guaranteed consent to treatment
covered entities are required to provide patients with a Notice of Privacy Practices & update as needed; good faith effort to get written acknowledgment of receipt Acknowledgment of HIPPA Notice
patient's signature authorizes exchange of personally identifiable health info between provider & other organizations consent to release information
form lists patient's rights when under care acknowledgment of patient rights
give instructions regarding patient's/guardian's wishes in special medical situations advance directives
effective Dec. '91 requires all patients older than 18 be given written info about their rights under state laws so they can make decisions concerning medical care, including right to refuse care Patient Self-Determination Act (PSDA)
special consent required to authorize any nonroutine diagnostic/therapeutic procedures before performed on patient consent to special procedures
consent to special procedures must include physician's explanation in lay terms to procedure named, risks of having/refusing procedure, avail alternative procedures & likely outcome in order for it to be valid
inventory of property & valuables brought by patient should admission be required property & valuables list
state laws require filing of vital records including birth and death certificates
Joint Commission requires a report of comprehensive H&P be completed & available within 24 hours, or sooner if surgery is to be performed
Joint Commission permits an interval history & phys exam when patient is admitted within 30 days for same reason
this key document is usually dictated and transcribed patient H&P
forms foundation for establishing provisional diagnosis and developing treatment plan medical history and review of systems
consist of chief complaint/description of symptoms, history current illness, medical history, family history, & social history including health maintenance & review of systems components of medical history
when a patient is a child/adolescent the Joint Commission requires including a developmental age evaluation & educational needs assessment
positive data on H&P all symptoms documentation
negative data on H&P = normal
adds objective data physical examination
subjective data patient history
if several diagnoses fit patient's clinical presentation, the list of alternatives is called differential diagnosis
interdisciplinary patient care plan is not required for physician's offices/clinic & acute-care hospitals
foundation around which patient care is organized because it contains input from unique perspective of each discipline involved interdisciplinary patient care plan
because of its central role in planning/providing care, the care plan is valuable for evaluating individual patient care and overall organizational patient care performance
are needed for any type of treatment/diagnostic procedure physician's orders
set of routine orders used for patients with particular diagnosis/prepare for/follow up a procedure standing orders
it is particularly important that all orders are dated and signed by LIP giving the order because they initiate action
Joint Commission requires that verbal/telephone orders for exchange of critical test results be verified through "read back" procedure
admission order is written at initiation of care
should be written for every patient once the physician determined release is appropriate discharge orders
lack of discharge order, in patient record, may indicate patient left against medical advice (AMA)
interval systems that document patient's illness & response to treatment as specifically as possible progress notes
contains an opinion about patient's condition by practitioner other than attending physician consultation report
require that medical staff bylaws, rules & regulations address status of consultations Conditions of Participation for hospitals
concisely reviews patient's course; should be written/dictated immediately after discharge or authenticated discharge/interval summary
procedures that require more than local anesthetic also require anesthesia report
describes planned procedure, choice of anesthetic, and exam of patient preanesthesia note
documents patient's condition, specifying nature & extent of any complications; should be completed within 24 hrs after surgery post anesthesia report
requires at least (1) postanesthesia visit that describes presence/absence of anesthesia-related complications Joint Commission
requires that recovery room report include patient's condition & level of consciousness when entering/leaving the unit the Joint Commission
all patient records, for patient's who undergo surgery must have an operative report
documents tissue exams that may be microscopic in addition to macroscopic pathology report
should be records in patient's record within 3days of autopsy provisional autopsy diagnosis
American College of Obstetricians & Gynecologists, identifies recommended content for obstetrical data in its Standards for Obstetric-Gynecological Services
begins in office or clinic of OB or nurse midwife & should be made available for access to hospital by 36 week of pregnancy antepartum record
tracks patient from admission through delivery to postpartum period labor & delivery record
includes information about condition of mother after delivery, with attention to assessing lochia & condition of breasts, fundus & perineum and postoperative status postpartum record
include regular history, physical exam, & progress noted, with addition of special identification data neonatal record
includes history regarding pregnancy, any diseases, delivery, Apgar score, any prematurities/abnormalities, & any problems occur before transfer to nursery birth history
while neonate is still in delivery room, 2 identical bands prepared noting mother's # & neonate's sex & time of birth, one band placed on mother & one on child; band # and ID form about mother & neonate also prepared neonatal identification
responsible for identification process & signs sheets along with any participating OB delivery room nurse
repeats birth & concentrates of detailed description of neonate's appearance neonatal physical exam
Joint Commission requires that neonates who receive oxygen therapy should have the concentration recorded at intervals according to policies/procedures of facility
regardless of the form, these notes describe patient & condition in objective, behavioral terms; includes interventions & patient's response as well as admission/discharge notes nursing notes
used to plot the patient's vital signs; usually includes 6 entries/day , nurses typically sign form once then initial thereafter graphic sheet
provides detailed record of medicines given orally, topically, or by injection, inhalation, & infusion; date, time, dose & route of administration included; practitioner giving dose signs sheet medication sheet
typically collected by practitioners other than physicians & nurses, w/exception of patient/family teaching and case & staff conferences where variety of clinicians participate ancillary data
records electrical activity of heart; electrocardiograph
shows 5 waves, P indicating contraction of atria, followed by Q,R,S & T consecutively which relate to contraction of ventricles normal electrocardiograph recording
graphic tracing produced by plotting the waves, against time on a continuous paper roll/computer view electrocardiogram
contains cardiologist's signed interpretation & may include tracing electrocardiographic record
when tracings are not provided, in the electrocardiographic record, they are stored in the laboratory for reference
detail analysis/exam of blood, urine, stool & other body substances; results provided by lab; should be completed/reported promptly; may be on standard paper/small slips designed for taping on mounting sheets laboratory reports
laboratory results can be profiled over time & presented in graphic format, when in an electronic view
American Association of Blood Banks has particular requirements, when blood baking is done, detailed in its Technical Manual
describe diagnostic/therapeutic services; procedures include modalities which create visual image; physician, usually a radiologist, dictates or writes description of image their impression radiology & imaging reports
the image can be viewed on-line & portion can be enlarged in a computerized view
films & computer images are stored in departments that produce them
closely resemble consultation process; major procedures requiring special consent; treatment plan written, each treatment reported incl. amount radiation given/dose & summary radiation therapy
radiation therapy reports are signed by therapeutic radiologists
include assessments & treatment plans designed to restore patient function; therapist documents services, incl. patient response & signs report/progress notes therapeutic services
therapeutic services notes are __ & __ oriented objective & goal
Joint Commission has documentation requirements for each of the therapeutic services, particularly as they relate to rehabilitative care
contain data on patient's background, social info, & problems identified by patient, family, & case mgr.; formal record includes plan of action, progress notes, & discharge note case management & social service record
has access to great deal of sensitive personal info in addition to private medical info case manager
wide variety of practitioners engage in __ & __ __ along the continuum of care patient & family teaching
regardless of profession/setting teaching & redemonstration of understanding should be described in detail; patient & family teaching & participation
patient & family teaching & participation, preprinted materials should be noted & kept on file in the HIM dept
family participation in planning, goal setting, & carrying out of lifestyle changes, therapies or other services may be required documentation by some segments of health care
begun at time of admission/initiation of services; gives general assessment of plans to maintain continuity after this episode of care discharge & follow-up plan
efforts that support communication, continuity of care, & overall high-quality patient care documentation guidelines
if health record is to fulfill unique roles for patient, providers, as legal record, for researchers, & education, content must be of high quality
must only document their own interactions, avoiding charting for others; legally responsible for their care & entries authors
help remind practitioners of care elements & essential documentation forms & views
should never be written in anticipation of care being provided because other events may intervene, creating errors in sequence of events notes
are best understood when they are specific & exact, including use of standard terms spelled correctly descriptions
notes do not require complete sentences
not a routinely require word, in chart notes, because it is understood "patient"
save substantial time for practitioners, but pose significant risk of being misunderstood through poor handwriting or duplicate meanings abbreviations, acronyms, & symbols
official list of approved abbreviations maintained by HCOs, to avoid misunderstandings from poor handwriting or duplicate meanings official abbreviations list
Joint Commission established national patient safety goals, prohibiting use of "dangerous" abbreviations, acronyms, & symbols in patient record
historic charting problems, such as legibility & author identification, are substantially resolved by the use of EHRs
promotes good quality photocopying, faxing, & document imaging for paper-based records use of blank ink
for paper-based records no __ __ should remain between entries blank lines
when errors occur, on paper-based records, corrections should be made with a __ __, so as not to obscure the entry single line
when errors occur, on paper-based records, corrections should be initialed and noted with "mistaken entry" or " error"
identifies an author of an entry in patient record & that entry has been verified/validated by the author authentication
prior to authentication __ or __ should be made to an entry additions or corrections
Joint Commission requires that the minimum of four documents be authenticated, including H&Ps, operative rpts, consultations, & discharge summaries
initials may be used, for authentication, when there is a __ available in record providing full signature & related initials legend
because of their high potential for abuse __ __ should be discouraged, for authentication signature stamps
e-mail signature, digitized image of signature, unique logon & PIN, unique biometric identifier, or digital signature using encryption are examples of electronic signatures
organization of paper-based health record is referred to as its format
reference that determines facility's standard sequence of pages to be followed in each record is called chart order
should approve forms to be used in clinical record as well as organizing format organization's info management or medical record committee
most common paper-based health record format; record is organized into sections according to practitioners who are the source of both treatment & data collection source-oriented medical record
in source-oriented medical record, within each section, sheets are arranged in ___ ___ chronological order
source-oriented medical record, during admissions current episode is typically kept at nursing unit in reverse chronological order
is record is kept in same order during & after care it may also be referred to as "universal" order chart
advantage of standardized source-oriented records is speed with which an individual sheet can be located
lack of clear picture of patient's problems & how each dept is contributing to their resolution is disadvantage of standardized source-oriented records
developed by Dr. Lawrence Weed in 1960s in response to major deficiency in source-oriented record format problem-oriented medical record (POMR)
system focuses on documentation of logical, organized plan of clinical thought by practitioners POMR
four part of the POMR database, problem list, initial plan & progress notes
the database of the POMR was early minimum data set (MDS)
dynamic document showing titles, numbers & dates of problems & serves as table of contents for the record POMR problem list
stated at the level of physician's current understanding & modified as further data accumulates; may include initial symptoms/well-defined diagnoses; past/present, financial, demographic & medical POMR problem
described what will be done to investigate/treat each problem; refer to problem number POMR initial plans
need to collect more decision-making info, therapy & patient education are the three types of POMR problem numbers
written in a distinctive style according to acronym SOAP & numbered to correspond to the problems POMR progress notes
considered a special progress note in the POMR discharge summary
creates holistic picture of patient & their care providing excellent communication & evaluation tool highlighting thinking process are all advantages of POMR
time &, commitment needed on part of practitioners to implement & maintain system are disadvantages of POMR
the full system of the POMR has not been widely accepted for use with paper-based health records, with exception to SOAP style progress notes & problems list
problem list & SOAP notes, are components of POMR used in ambulatory settings
list of goals & objective, serving same function as problem list were transformed for use by behavioral health
behavioral health may use modification of SOAP notes that combines "S' & "O" into "Data"
data, assessment, and plan used to structure progress notes DAP
strictly chronological without any divisions by source, keeps episode of care clearly defined by date integrated medical record
keeping episode of care clearly defined by date, is an advantage of integrated records when the __ __ __ is considered flow of care
info from same source is not easily compared, is disadvantage of integrated medical records
resemble team approach of POMR, providing more holistic view of patient progress notes of integrated medical records
particular way of looking at data in a database; organizes data visibly in way that meets needs of user; permit recording of varying data w/out recopying constant info view
different views do not affect the physical ___ of the database organization
when well designed & controlled they enhance tech by providing smooth link in communication process forms, views & templates
should emphasize the needs of the user form or view design
plays leadership role by providing knowledge of rules & regulations related to health record content, medical science, computer applications, flow of data, & info needs of health care delivery system HIM Professionals
collecting enough of the right type of data to satisfy the range of users means clearly defining the purpose of the form or view
identify patients & practitioners & instruct them step by step in what data items to gather, where to obtain them & how to record them forms
facilitate complete and accurate documentation is the foundation of effective decision making
all elements of history, review of systems, and physical exam are collected when standardized
the history & physical form or view ___ majority of communication between patient & practitioner, and others as the need arises structures
effective & efficient sequencing of form/view should follow from left to right and top to bottom
makes referencing to both items & written instructions on completion of forms easier and faster numbering items
when standard definitions are not available the form/view should provide the definition
standard definitions are particularly important when linked databases are used
aspect of form/view design, which promotes consistency, is development of master format/template
should briefly identify who should complete data items & provide any additional guidance necessary instructions
reference to the location of instructions should be made on the face of the form
provides considerable savings in time, effort & materials simplification
necessary to standardize assembly of sequence of various document within paper health record, also called chart order a guide
title & subtitle identifying the form are typically positioned in the header
the title & subtitle, identifying the form, should appear at the bottom when the facility binds records at the top
on each form the form titles should appear in the same font & font size
contains info about the form, such as control number, edition date & page number/letters, usually at the left the footer
operative report should be dictated/written ___ after surgery, signed & put in the records ___ immediately; ASAP
on paper forms, there should be a place to imprint the patient's __ & __ on all pages of a multipage form/on each side of double-sided form name & health record number
should explain purpose of the form; usually title sufficient, occasionally subtitled needed to understand form to complete appropriately Introduction & Instructions on paper forms
contains main content of paper form body
on paper forms, provides space for authenticating or approving signatures close
NCR no-carbon required
when creating a paper form, the creator must take into consideration the spacing in order to compensate for 1/3" vertical height, for handwritten words
when creating a paper form, __ should be well chosen and contribute to readability type styles, or font(s)
vertical/horizontal lines that structure a paper form; serve to divide form into logical sections, & direct data entry length & location rules
for paper form(s), if several people have areas to complete, data sets each party is to present should be presented in the order of completion
desirable on paper form(s) for long sections that are handwritten horizontal lines
should be located in upper left of the boxes in small font sizes box titles or captions
sometimes called ballot boxes; when used there should be consistency throughout form, whether located on immediate left/right of the caption check boxes or line
vertical/horizontal line rules, check boxes or lines should be aligned ___ when appropriate vertically
rules that frame a section; preferable to screening/shading; can create a margin around an entire form borders
provide visual appeal & important for printing; allowances should be made for punched holes & printing equipment margins
forms to be types should have, at least, ___ ___ at bottom to avoid paper slippage in platen when typing near bottom of the page 1/2" margin
if data is to be entered on computer screen/view & then printed on preprinted paper forms, refer to ___ or ___ ___ for correct data placement vendor or machine specifications
original from which copies of paper form(s) are made; may be designed internally; when elaborate/formal printing needed should be created by professional typesetter masters
refers to a paper form(s) size and special properties physical building
require planning to provide sufficient copies & construction; packet creates precollated & prefastened w/ perforated stub; advantages - standardization multipart paper form(s)
disadvantages: limited # of copies, carbon must be removed, ink smears, NCR difficult to read beyond 1st 2-3 pg, ink can fade over time, & photocopying impossible to read paper multipart form(s)
may be produced as individual form sets or continuous-feed strips paper-based form(s)
paper-based form(s) prepared as unit sets consisting of single forms glued together along one edge, which create a pad of paper-based form(s)
reflects how easy the paper is to read & write on suitability
concerns how well paper-based form(s) stands up to handling durability
reflects how long paper-based form(s) lasts in hard copy permanence
extremely important to be suitable for use w/copiers, fax, & scanning equipment; 20-24lbs recommended for health records paper weight
ink type best suits reproduction & should meet scanning specifications black ink
use of ___ ___ ___ should be limited because it adds to the cost of the form additional text colors
include in-house preparation & commercial printing duplicating
entails the creation of master & reproduction, usually by photocopy; more expense; used for trial period/when only small amount of forms needed include in-house preparation
process in which a lithographic stone or metal or paper plate is used to make an inked impression on a rubber blanket that transfers it to the paper being printed, instead of being made directly on the paper offset printing, offset lithography
more cost effective, the in-house master can be used for offset printing
best for providing added features (i.e. hole punching, perforation, collating, etc.) in conjunction w/printing process commercial printers
provide definitions for data elements that comprise a data set; should provide agreed-to definitions for each data element in data set & include additional information needed to properly construct data set data dictionaries
grouping of data elements into data element groups; includes logical groupings of data elements; sometimes given names & defined in data dictionary in a manner similar to less complex data elements element group
specification of the allowable values for each data element; allowable values expressed as enumerated list of values, reference to enumerated list of values, or predicate expression describing allowable values element domain
specification of allowable values may include constraints based upon the value of one or more other data elements in the data set
specification of conditional presence for each data element element default
may be specified for optional data elements; specification of what the recipient of the data set can assume to be the value for data elements not sent in the data set default value
specification of the derivation algorithm for derivable data elements element derivation
may be as simple as counts, sums, differences, and averages, or may involve complex rules and procedures derivable data elements
Data sets containing derivable data elements will sometimes also include the raw data needed to perform derivation for audit or data validation purposes
involves collecting data definitions currently in use, assessing the disparity in data definitions, and reconciling the discrepancies data dictionary project
generally contains technical, business, & clinical definitions for data & includes instructions for mapping technical definition in a computer system to agreed-to business/clinical definition for use in info collection, analysis, & dissemination resulting data dictionary
developing a data dictionary is a critical step in the implementation of computerized patient record system or clinical data warehouse
regulatory & accrediting bodies such as the Health Care Financing Administration & the Joint Commission on Accreditation of Healthcare Organizations also produce data dictionaries as part of data set specifications
defined collection of data elements for a particular business or clinical purpose data set
software developers, regulators, accrediting agencies, government agencies, researchers, payer organizations, provider organizations, & standards bodies have all defined data sets in healthcare
level of abstraction in a data set can range from very specific to somewhat conceptual
more complex the data set, the more important it is that the parties who will be using it agree on data set definitions & rules for data set's construction
data dictionary must accompany the data set
because data elements are reused across data sets, it is ideal if elements in different data sets can be drawn from a common data dictionary
dictionary needs to be organized in a way that makes it relatively easy to find desired data __ & to detect unintended data __ element; redundancies
data models have become a popular and effective means of meeting the requirements of reusable data dictionary
provide a contextual framework & graphical representation that aid in definition of data elements; data elements are organized into classes, & each class represents some object in healthcare data models
can be a concept, person, place, thing, or event an object in a data model
contains a description of the class of objects it represents; set of properties that include the attributes & associations to no other in the model class in a data model
some fact of interest about the class that could be carried in a data element of a data set attribute
two popular and widely used standards for data modeling; provide a formal language for expressing and defining classes of concepts and their properties IDEF6 and UML7
are an effective means of capturing useful, normalized groupings of data elements classes w/in a data model
capturing element conditionality, defaults, and derivation specification in the data model is best delayed until using data model to define data sets
should be added to the data model's data dictionary as an extension of the model specifications in data model
significant advantage of keeping derived data elements out of the base data model and out of the graphical expression is reduction of redundant data definitions
contains non-derived, unique, atomic data elements core data dictionary
contains derived, qualified, & composite data elements extension to core data dictionary
require data elements to convey concepts that are unique w/i scope of model & not encapsulation of significant subordinate concepts rules of data modeling
rules of data modeling are known as normalization
normalization enables construction of data model that is resilient, extensible, & applicable to multiple users
data elements included in the extended data dictionary are not constrained by rules of normalization
used in data sets are defined in the extended data dictionary, along with their rules for derivation derived data elements
may also be defined in extended dictionary as equivalent to data elements in core data dictionary alias names for data elements
description should include text that explains when it is to be used alias
convey concepts that are a subset of a concept in the core data dictionary qualified data elements
contains qualifier word preceding name of a core data element name of qualified data element
declares the subset qualifier word
extended data dictionary might also include data elements that are ___ of data elements included in core data dictionary composites
contents of the extended data dictionary are best defined during the process of building a specification for a data set
data sets derived from a data model will have their entire contents drawn from the data model data dictionaries
new data element is added to the core data dictionary, it must also be added to the data model's graphical representation
more the data model is used as the source of data elements for data sets, the more complete it becomes and the more useful it is as a tool for ensuring consistency among multiple data set
complement each other & , when used together, enhance their effectiveness in creating well-defined, semantically rich, reusable data elements features & advantages of data dictionaries, data sets, & data models
is an example of data model-driven approach to constructing data dictionaries and data sets, to achieve consistency in data element and data set definitions HL7 version 3 message development methodology