Chapter 6 - Data Management

Question 1

system characterization

Answer 1

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

Question 2

data element

Answer 2

a single or individual fact that represents the smallest unique subset of a larger database

Question 3

Uniform Ambulatory Care Data Set (UACDS)

Answer 3

a data set that collects data specific to ambulatory care settings with an intent to improve data comparison across different settings of healthcare

Question 4

Essential Medical Data Set (EMDS)

Answer 4

a data set used in emergency care settings

Question 5

database life cycle (DBLC)

Answer 5

a term which refers to the four phases of database creation: requirements analysis, design, implementation, and maintenance

Question 6

index

Answer 6

a list, usually arranged in alphabetical order of some specified datum (such as author, subject, or keyword) (e.g. publicly traded companies, citations)

Question 7

source data

Answer 7

the location from which the data originates, such as a database or a data set

Question 8

target data

Answer 8

the location from which the data are mapped or to where the data are sent

Question 9

information assets

Answer 9

the information collected during the day-to-day operations of a healthcare organization that has value within the healthcare organization

Question 10

business intelligence (BI)

Answer 10

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

Question 11

SBAR tool

Answer 11

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)

Question 12

enterprise information management (EIM)

Answer 12

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

Question 13

AHIMA Information Governance Principles of Healthcare (IGPHC)

Answer 13

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

Question 14

standards development organizations (SDOs)

Answer 14

private or government agencies that are involved in the creation and implementation of healthcare standards

Question 15

data interchange standards

Answer 15

standards that govern the exchange of data between businesses, government entities, libraries, and non-governmental organizations

Question 16

American National Standards Institute (ANSI)

Answer 16

the organization that oversees the creation of data standards from a variety of business sectors, including healthcare

Question 17

critical thinking

Answer 17

the process of analyzing, assessing, and reconstructing a situation to provide enhanced solutions and outcomes to a problem

Question 18

data visualization

Answer 18

the graphical representation of information and data

Question 19

data quality management model

Answer 19

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

Question 20

forms design

Answer 20

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

Question 21

clinical documentation integrity (CDI)

Answer 21

the process of reviewing medical information to verify that documentation is clinical specific, is appropriate, and supports the medical codes assigned

Question 22

CDI review process

Answer 22

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

Question 23

case mix index (CMI)

Answer 23

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.