Clinical Terminologies, Classifications and Code Systems
A set of terms specific to a domain
What is vocabulary/terminology?
The definition and structure of data elements and the creation, storage and transmission of data elements
What is Data Management?
A database created from Medicare claims
What is MEDPAR?
CMS
What is the Centers for Medicare and Medicaid?
A system of names that follows preestablish conventions
What is nomenclature?
Create process for removal and/or destruction of information no longer needed.
What is disposition?
Used by external users to identify patterns and trends
What is secondary data?
OASIS
What is the Outcome Assessment Information Set?
A standardized nomenclature for clinical drugs
What is RxNorm?
Create a process for proper retention based on accreditation, all laws, regulations, standards and organizational policies
What is retention?
Include data on groups of people or patients without identifying any particular patient individually
What is aggregate data?
UHDDS
What is the Uniform Hospital Discharge Data Set?
Classifies states of functioning, disability and health
What is ICF?
All information complies with all laws, regulations, standards and organizational policies
What is compliance?
Responsible for the clinical trials database
What is The National Library of Medicine?
DEEDS
What is the Data Elements for Emergency Department Systems?
Contains the codes and terms from over 200 terminology, classification and coding standards
What is metathesaurus?
Create protections to safeguard information from improper use and disclosure to avoid data breaches
What is protection?
A list of publications for healthcare
What is MEDLINE?
EDMS
What is the Essential Medical Data Set?