Chapter 6 - Data Management Flashcards
system characterization
the process of creating an inventory of all systems that contain data, including documenting where the data are stored, what types of data are created or stored, how they are managed, with what hardware and software they interact, and providing basic security measures for the systems
data element
a single or individual fact that represents the smallest unique subset of a larger database
Uniform Ambulatory Care Data Set (UACDS)
a data set that collects data specific to ambulatory care settings with an intent to improve data comparison across different settings of healthcare
Essential Medical Data Set (EMDS)
a data set used in emergency care settings
database life cycle (DBLC)
a term which refers to the four phases of database creation: requirements analysis, design, implementation, and maintenance
index
a list, usually arranged in alphabetical order of some specified datum (such as author, subject, or keyword) (e.g. publicly traded companies, citations)
source data
the location from which the data originates, such as a database or a data set
target data
the location from which the data are mapped or to where the data are sent
information assets
the information collected during the day-to-day operations of a healthcare organization that has value within the healthcare organization
business intelligence (BI)
the end product or goal of knowledge management. In other words, it is what you can do with what you know about your healthcare organization, your community, and so forth
SBAR tool
The SBAR Elements (an information governance tool)
S = Situation (a concise statement of the problem)
B = Background (pertinent and brief information related to the situation)
A = Assessment (analysis and consideration of options—what you found/think)
R = Recommendation (action requested/recommended—what you want)
enterprise information management (EIM)
the set of functions created by a healthcare organization to plan, organize, and coordinate the people, processes, technology, and content needed to manage information for the purposes of data quality, patient safety, and ease of use
AHIMA Information Governance Principles of Healthcare (IGPHC)
eight principles for information governance; they are:
(1) accountability
(2) transparency
(3) integrity
(4) protection of data
(5) legal compliance
(6) easily available data
(7) proper retention of records
(8) proper disposal of records
standards development organizations (SDOs)
private or government agencies that are involved in the creation and implementation of healthcare standards
data interchange standards
standards that govern the exchange of data between businesses, government entities, libraries, and non-governmental organizations
American National Standards Institute (ANSI)
the organization that oversees the creation of data standards from a variety of business sectors, including healthcare
critical thinking
the process of analyzing, assessing, and reconstructing a situation to provide enhanced solutions and outcomes to a problem
data visualization
the graphical representation of information and data
data quality management model
a model used by AHIMA that consists of four domains of data quality: application of lessons learned from data, collection of data, data warehousing, and data analysis
forms design
the oversight process in which paper forms are created to make sure that they are easily understood and to collect the correct amount of information necessary
clinical documentation integrity (CDI)
the process of reviewing medical information to verify that documentation is clinical specific, is appropriate, and supports the medical codes assigned
CDI review process
a seven-step process for CDI encouraged by AHIMA:
(1) documents must be legible
(2) documents must be reliable
(3) documents must be precise
(4) documents must be complete
(5) documents must be clear
(6) documents must be consistent throughout
(7) documents must be completed on time
case mix index (CMI)
a measure used by the Centers for Medicare and Medicaid Services (CMS) to determine hospital reimbursement rates for Medicare and Medicaid beneficiaries. This measure reflects the diversity, complexity, and severity of patient illnesses treated at a given hospital or other healthcare facility.
