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Ch 14 Key Words

Abstracting (1) A process by which a set of predetermined data is obtained from the patient record and related sources; (2) the process of selecting specific data items from medical records for clinical and administrative decision making
Accessioned When patients are determined eligible and added to a registry
Active Case Ascertainment Surveillance Systematic review of cases in all hospitals, clinics, or other medical facilities or interviewing health professionals who may be knowledgeable about diagnosed cases
Attribute Data element that describes the entity; represented as a column in a table
Bioterrorism An intentional human release of naturally occurring or human-modified toxin or biological agent
Case A person with a given disease or condition that is under study
Case Eligibility All of the organization's patients diagnosed and/or treated for ative diseases on or after the reference date or beginning of the registry are eligible for inclusion in the registry
Case Finding The method by whch all of the eligible cases to be included in the registry are identified, accessioned into the registry, and abstracted
Clinical Case Definition A list of signs and symptoms that establish a clinical diagnosis
Clinical Decision Support Provides diagnostic investigation tools and clinical guideline advice to patient care providers
Comorbidity A condition that is in addition to a primary condition and affects course or treatment of a condition or length of stay
Core Measure A set of standardized metrics developed and used by The Joint Commission to assess the quality of health care organizations
Data Dictionary Serves as the central repository for all information about the database and functions as a catalog for identifying the nature of all the data in a system
Data Element The atomic level of information; a single question that demands a singular defined response
Data Warehouse Receives clinical data from a transactions system such as a pharmacy system or radiology system and combines them with other organizational data from administrative and financial systems
Differentiation A term used for variation from normal tissue
Entities Represents a higher level than the data element; refers to a subject of information that may be a thing, a concept, or a process
Epidemiologic Case Definition A definition set as a reportable condition by the Centers for Disease Control and Prevention and must be reported to a public health agency
Etiology The study of the causes of disease
Field A physical term that refers to the place in a computer system in which a data element might reside
Follow-up The processes used by cancer registries to determine the cancer patient's status
Grading Variation from normal tissue; differentiation; used in the description of tumors
Incidence The number of new cases of disease
Logical Data Model Represents the structure of the relationship of data elements and entities within an information system
Major Birth Defects Birth defects that affect sirvival, require substantial medical care, or result in marked physiological or psychological impairment
Metadata Defined as "data about data;" defines structure to be used to define all characteristics about data so that different individuals looking at characteristics of data element would arrive at same conclusion as to what data means and how it is to be used
Morphology Cell structure and form
Outcome Refers to an indicator of the results of a process
Passive Case Used to describe reporting systems that rely on reports submitted to the registry by hospitals, clinics, or other facilities, supplemented with data from vital statistics
Pay-for-Performance Payment system initiated by some health plans that financially rewards providers who achieve specific quality or patient safety goals
Population-Based Registry A registry that collects data for a defined geographic area
Primary Data The information contained in the atucal patient record
Record A row within the table that contains data elements within fields that will provide sufficient data to identify a unique instance of the entity
Reference Date The date the registry began accessioning cases
Secondary Data The information that is generated from the patient record
Stage The extent of the spread of the disease
Surveillance The collection, collation, analysis and dissemination of data
Table The physical representation of the entity
Topography Site or location of a neoplasm
Value/Coding Represents a more specified way that values may be returned to the data element question
Created by: djcobb