1.2 Healthcare Data, Data Sets And Standards Flashcards
Organized data
Information
Health data that has been organized
Health information
What is the order when describing data
- data type (numeric, alpha, free text)
- Characters
- Fields
- Records (everything put together demographics)
- Files
- Data sets
A letter, a single-digit number, or symbol
Characters
A series of related characters that have a specific relationship to one another
Fields
Example of fields are
zipcode, dob, phone
Combination of fields that have a logical connection to one another.
Records
Examples of records are
patient demographic record, patient Diagnosis and procedure record, insurance recordand EMR Encounter record
A group of related records of different types of data
files
Gives examples of file
files submitted to a coding system, files created by billing system and transmitted to payer, PHR file downloaded form pt Portal
What is the name of the who file that is given to the payer
EDI
A group of elements collected in a standard method for a specific purpose so then they can be utilized in a business function and/ or for research
Data sets
Generated
- as a by-product of HIT function (registration and discharge)
- by “abstracting
Data sets
What does UHDDS
Uniform Hospital Discharge Data Sets (Acute Care)
What is the role of UHDDS
data must be submited to CMS
UACDS
Uniform Ambulatory Care set
MDS
Minimum Data Set (Long term care)
DEEDS
Data Elements for Emergency Department (ER)
OASIS
Observation and Assessment Information Set (home health care)
In Minimum Discharge Data Sets data is
always available to use/share
Minimum core data set collected on individual hospital discharges for the Medicare and Medicaid programs
Minimum Discharge Data Sets
Data related to: patient, provider, and encounter and collected in EMR-usually collected
Minimum Discharge Data Sets
Name the UHDDS Fields
personal identification/unique indentifier
DOB
Gender
Race and ethnicity
Address
health care facility identification number
Admission date and type of admission
d/c date
attending physician identification number
surgeon identification number
d/c date
disposition of patient at discharge (how the patient go in)
expected payer for most of this bill
total charges
What UHDDS field is the condition established after study to be chiefly responsible for occasioning the admission of the patient to the hospital for care
UHDDS Field called Principal diagnosis
medical records assigns
determines the rate of reimbursement
reason for admission
principal diagnosis field for UHDDS
The UHDDS field that affects how pt is being cared for
secondary UHDDS field
procedure performed for definitive or therapeutic reasons; most closely related to the principal diagnosis. what UHDDS field
principal procedure and date the high end diagnostic test
enable creation of a continuity of care document utilized by
HIE
CCD
Continuity of Care Document
make it possible to electronically transmit data and information form one system to another
Electronic Data Interchange EDI
eliminated data mapping from one system to another
EDI– standard
facilitates research using data sets combined from many providers- medicare is widely used and available to the public
EDI standards -
Items, observations, raw facts,
Data
