RHIA (Domain I) Data Content Structure and Standards

Uniform data set:

Clinical information is the basis for it. When clinical information from many patient records is combined, a data set can facilitate the comparison of patient information from multiple sources.

One to many identified as I:M:

a patient may have many visits to the ambulatory clinic, but each visit is attributed to only one patient. A patient is "one" is related to the visits "many

Standard:

expected behavior against which structures, processes, and outcomes can be measured 2. A model or example established by authority, custom, or general consent or a rule established by an authority as a measure of quantity, weight, extent, value, or quality 3. Under HITECH, a technical, functional, or performance-based rule, condition, requirement, or specification that stipulates instructions, fields, codes, data, material, characteristics or actions (45 CFR 170.102 2012) 4. As amended by HITECH at section 160.103, a rule, condition, or requirement: (1) describing the following information for products, systems, services, or practices: (i) classification of components; (ii) specification of materials, performance, or operations; or (iii) delineation of procedures; or (2) with respect to the privacy of protected health information (45 CFR 160.103 2013).

Data definition:

special type of software used to create the tables within a relational database, the most common of which is structured query language.

Chief complaint

(is a reason for visit), is the nature and duration of the symptom that caused the patient's illness and caused the patient to seek medical attention as stated in the patient's own words.

Informed consent:

1. A legal term referring to a patient's right to make his or her own treatment decisions based on the knowledge of the treatment to be administered or the procedure to be performed 2. An individual's voluntary agreement to participate in research or to undergo a diagnostic, therapeutic, or preventive medical procedure.

Source system:

1. A system in which data was originally created 2. Independent information system application that contributes data to an EHR, including departmental clinical applications (for example, laboratory information system, clinical pharmacy information system) and specialty clinical applications (for example, intensive care, cardiology, labor and delivery). The code or data set from which the map originates is the.

Integrity :

1. The state of being whole or unimpaired 2. The ability of data to maintain its structure and attributes, including protection against modification or corruption during transmission, storage, or at rest. Maintain of it is a key aspect of data quality management and security

Unique identifier number:

A combination of numbers or alphanumeric characters assigned to a particular patient

Hybrid health record:

A combination of paper and electronic records; a health record that includes both paper and electronic elements. These record are the most difficult to manage because what is in paper and what is electronic may be consistently changing while the organization will have to comply with the regulations for both paper records and EHRs.

Unified modeling language (UML):

A common data-modeling notation used in conjunction with object-oriented database design.

Certificate of destruction:

A document that constitutes proof that a health record was destroyed and that includes the method of destruction, the signature of the person responsible for destruction, and inclusive dates for destruction.

Foreign key (FK):

A key attribute used to link a column or data point in one table to the column or data point in another table.

CMI (case mix index):

A measure of the resources used in treating patients in each or group of hospitals. 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.

Report cards:

A mechanism to evaluate the quality of care delivered by health plans. They provide information on how well a health plan treats its members, keeps them healthy, and provides access to care (CMS 2013).

Accession number:

A number assigned to each case as it is entered in a cancer registry.

Unique identifier:

A number that is assigned to link patients to their records. This number is used on all record forms and views to collect all patient data in the correct record or to be accessed by computer database query.

Many to many refer to as M:M :

A patient may have many physicians and each physician may have many patients.

Case management:

A process used by a doctor, nurse, or other health professional to manage a patient's healthcare 2. The ongoing, concurrent review performed by clinical professionals to ensure the necessity and effectiveness of the clinical services being provided to a patient.

Unified Medical Language System (UMLS):

A program initiated by the National Library of Medicine to build an intelligent, automated system that can understand biomedical concepts, words, and expressions and their interrelationships; includes concepts and terms from many different source vocabularies (NLM 2013).

Entity relationship diagram (ERD):

A specific type of data modeling used in conceptual data modeling and the logical-level modeling of relational databases. A diagram used principally to illustrate the logical design of information system database by describing entity attributes. This is accomplished by describing diagrammatically the relation between entities and by identifying entity attribute. Are composed of three categories of items: entities, relationships, and attributes.

Resident assessment protocol (RAP):

A summary of a long-term care resident's medical condition and care requirements, used in conjunction with the MDS to create a clear picture of the patient's status and care plan. Help facility staff evaluate triggered condition. Form a critical link to decisions about care planning and provide guidance on how to synthesize assessment information within a comprehensive assessment.

Universal chart order:

A system in which the health record is maintained in the same format while the patient is in the facility and after discharge.

Source-oriented health record format:

A system of health record organization in which information is arranged according to the patient care department that provided the care

Structured data entry Also called discrete data:

A type of healthcare data documentation about an individual using a controlled vocabulary rather than narrative text.

Unique user identifier:

A unique identifier assigned to all authorized users of the health record and used to track users and log-in procedures.

One to one:

An ICD-9-CM code has only one description, and the ICD-9-CM description has only one ICD-9-CM code

SOAP:

An acronym for a component of the problem-oriented medical record (POMR) that refers to how each progress note contains documentation relative to subjective observations, objective observations, assessments, and plans.

Primary key (PK):

An explanatory notation that uniquely identifies each row in a database table; See key field. The unique patient identifier, to eliminate storing the patient's name and other demographics in the visit table.

Clinical documentation:

Any manual or electronic notation (or recording) made by a physician or other healthcare clinician related to a patient's medical condition or treatment. (entered as text not easily automated due to the unstructured nature of the information).

Transfer Record:

Are created whenever a patient is transferred from one facility to another. Contain a summary of the care provided in the facility from which the patient is being transferred as well as the reason for transfer. In addition is important to the continuum of care because they document communication between caregivers in multiple setting.

Authorization copy:

As amended by HITECH, if a covered entity seeks an authorization from an individual for a use or disclosure of protected health information, the covered entity must provide the individual with a copy of the signed authorization (45 CFR 164.508 2013

Aggregate data:

Data extracted from individual health records and combined to form de-identified information about groups of patients that can be compared and analyzed. Data that collected on large population of individuals and stored in database

Coded data:

Data that are translated into a standard nomenclature of classification so that they may be aggregated, analyzed, and compared.

Retention program:

Determine the format and location of record storage, assigning each record a time period for preservation, and destroying records that are no longer needed.

Minimum data set MDS

Document created when OBRA required CMS to develop an assessment instrument to standardize the collection of SNF patient data; the is the minimum core of defined and categorized patient assessment data that serves as the basis for documentation and reimbursement in an SNF.

Emergency care record:

Include the time and means of arrival, treatment rendered, and instructions at discharge. Facilities are required to so a pertinent history, including the chief complaint and onset illness or injury but not complete medical history of the patient.

Master patient index (MPI):

Index that identified all patients who have been treated by the facility and lists the number associated with the name. The index can be maintained manually or as part of a computerized system.

Demographics:

Information used to identify an individual, such as name, address, gender, age, and other information linked to a specific person. Personal data elements, sufficient to identify the patient, collected from the patient or patient representative and not related to health status or services provided.

Author:

Is a person or system who originates or creates information that become part of the record.

Clinical data:

Is collected and recorded during the intake process. The treating or physician can provide the patient's preliminary diagnosis and the reason the patient's is seeking treatment. It's important because it became the basis of care plans and helps determine medical necessity.

Health record matrix:

It is the best practice to create, to identify and track the physical location of each paper document and the source of each electronic document that constitute the LHR. It's the best practice to establish a policy statement on the maintenance of it.

Consent:

Legal permission given by a patient or a patient's legal representative to a healthcare provider that allows the provider to administer care and treatment or to perform surgery or other medical procedures.

Outcome measures:

Performance measures that examine the end results or product of the patient's encounter with the system. The process of systematically tracking a patient's clinical treatment and responses to that treatment, including measures of morbidity and functional status, for the purpose of improving care 2. A measure that indicates the result of the performance (or nonperformance) of a function or process.

Abbreviations:

Shortened forms of words or phrases; in healthcare, when there is more than one meaning for an approval. only one meaning should be used or the context in which the --- is to be used should be identified.

Core measure/core measure set:

Standardized performance measures developed to improve the safety and quality of healthcare (for example, core measures are used in the Joint Commission's ORYX initiative).

Legal health record (LHR):

The data and information within the patient record used to substantiate the care given for reimbursement and quality proposes. It is also a legal document that confirms whether treatment was delivered in a manner appropriate for the given health problem. The record is used to shoe proof in a court of law of what transpired during the course of a patient's illness and treatment. As a record that is "generated at or for a healthcare organization as its business record and is the record that would be released upon request". Physically exist in separate and multiple paper-based or electronic system. This complicate the process of pulling the entire records

Health record ownership:

The generally accepted principle that individual health records are maintained and owned by the healthcare organization that creates them but that patients have certain rights of control over the release of patient-identifiable (confidential) information.

Secondary data:

The information that is generated from the patient record. Data derived from the primary patient record, such as an index or a database. Valuable resource for research, program evaluation, education, and public health studies. Also data are stored in government and private databases and are used in the aggregate for these purpose.

Emergency situation:

The only situation that not include a report of a complete history and physical conducted no more than seven days before the surgery is to be performed.

Authorship:

The origination or creation of recorded information attributed to a specific individual or entity acting at a particular time.

Data governance (DG):

The overall management of the availability, usability, integrity, and security of the data employed in an organization or enterprise (Data Governance Institute). Decision making and authority over data-related matters.

Auditing:فحص ، تدقيق

The performance of internal or external reviews (audits) to identify variations from established baselines (for example, review of outpatient coding as compared with CMS outpatient coding guidelines)

Data mapping:

allows for connections between two systems. This connection allows for data initially captured for one purpose to be translated and used for another purpose. One system in a map is identified as the source while the other is the target. 2. Process by which two distinct data models are created and a link between these models is defined. 3. A process used in data warehousing by which different data models are linked to each other using a defined set of methods to characterize the data in a specific definition. This definition can be any atomic unit, such as a unit of metadata or any other semantic. This data linking follows a set of standards, which depends on the domain value of the data model used. Data mapping serves as the initial step in data integration.

The record correction:

in paper record the provider should draw a single lone through the error, add a note explaining the error, initial and date the error with the date it was discovered, and enter the correct information in chronological order. In electronic entries a procedure should be followed that explains how to correct errors and enter addenda to the health record.

Heath record matrix:

is the best practice to identify and tracks the physical location of each paper document and the source of each electronic document that constitute the legal health record. In addition to defining the content of the legal health record and best way to establish a policy statement on the maintenance of it.

Authentication:

is the process by which a user ( a person or entity) who authored an HER entry or document is seeking to validate that they are responsible for the data contained within it.

Mask:

the use of it, tell the database what format to use to display the number, such as social security number (xxx-xx-xxxx).