Chapter 6: Vocabulary

Question 1

Bylaws

Answer 1

Written documents that provide details and information regarding the rules and regulations established by a healthcare organization to help support healthcare operations.

Question 2

Clinical Documentation

Answer 2

Any manual or electronic notation (or recording) made by a physician or other healthcare clinician related to a patient’s medical condition or treatement.

Question 3

Critical thinking

Answer 3

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

Question 4

Data

Answer 4

A representation of basic facts and observation about people, processes, measurments, and conditions.

Question 5

Database

Answer 5

A collection of data organized in such a way that its contents can be easily accessed, managed, reported, and updated.

Question 6

Database Life Cycle

Answer 6

An important step in the proper execution, implementation, and management of databases within healthcare. (DBLC)

Question 7

Data Dictionary

Answer 7

A listing of all the data elements within a specific system that defines each individual data element, standard input of the data element and specific input of the data element, and specific data length.

Question 8

Data Element

Answer 8

Can be single or individual fact that represents the smallest unique subset of a larger database sometimes referred to as the raw facts and figures.

Question 9

Data Governance

Answer 9

Enterprise authority that ensures control and accountability for enterprise data through the establishment of decision rights and data policies and standards that are implemented and monitored through a formal structure of assigned roles, responsibilities, and accountabilities.

Question 10

Data Integrity

Answer 10

The assurance that the data entered into an electronic system or maintained on paper are only accessed and amended by individuals with the authority to do so.

Question 11

Data Interchange Standards

Answer 11

Developed in order to support and create structure with data exchanges to sustain interoperabilility.

Question 12

Data Management

Answer 12

Refers to defination and structure of data elements and the creation, storage, and transmission of data elements.

Question 13

Data Mapping

Answer 13

A process that allowed for connections between two systems.

Question 14

Data Mining

Answer 14

The processing of extracting from a database or data warehouse information stored in discrete, structured data format– that is, data that has a specific value

Question 15

Data Sets

Answer 15

A recommended list of data elements that have defined and uniform definitioms that are relevant for a particular use or are specific to s type of healthcare industry.

Question 16

Data Stewardship

Answer 16

Creates responsibility for data through principles and practices to ensure the knowledgeable ad appropriate use of data derived from indiciduals’ personal health information.

Question 17

Data Warehouse

Answer 17

A single database that makes it possible to access data that exists in multiple databases through one single query and reporting interface.

Question 18

Data Warehousing

Answer 18

The process of collecting the data from different data sources within an organization and storing it in a single database that can be used fro decision making.

Question 19

Enterprise Information Management

Answer 19

Is the set of functions created by an 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 20

Index

Answer 20

A report or list from a database that provides guidance, indication, or other references to the data contained int he database.

Question 21

Information

Answer 21

Is different that data as it refers to data elements that have been combined and then manipulated into something meaningful regarding a patient or a group of patients.

Question 22

Information Assets

Answer 22

Refer to the information collected during day-to-day operations of a healthcare organization that has vakue within an organization.

Question 23

Information Governance

Answer 23

Focuses on principles and oversight to manage the information that is produced from the different systems within an organization.

Question 24

Interoperability

Answer 24

The capability of two or more information systems and software applications to communicate and exchange information.

Question 25

Object-oriented Database

Answer 25

Designed to store different types of data including images, aduio files, documents, videos and data elements.(OODB)

Question 26

Query

Answer 26

A communication tool for CDI staff to communicate with providers to obtain clinical clarification, provide a documentation alert, clarify documentation, or as additional questions regarding documentation.

Question 27

Relational Database

Answer 27

Stores data in tables that are predefined and contain both rows and columns of information.

Question 28

Source Data

Answer 28

The location from which the data is mapped or to where it is sent.

Question 29

Standards Development Organization

Answer 29

Private or government agencies that are involved in the creation and implementation of healthcare standards. (SDOs)

Question 30

Structured Data

Answer 30

Data that are able to be read and interpreted by a computer.

Question 31

System Characterization

Answer 31

The process of creating an iventory of all systems that contain data, including documenting where the data are stored, what type of data are created or stored, how they are managed, with what hardware and software they interact with, and providing basic security measures for the systems.

Question 32

Target Data

Answer 32

The location from which the data is mapped or to where it is sent.

Question 33

Unstructured Data

Answer 33

Also known as free text, is data entered into the system with no format specified.

Question 34

Use Case

Answer 34

Describes how the users will interact with the data map in a specific scenario.