Clinical Terminologies, Classifications and Code Systems
Data Management
Secondary Data Sources
Healthcare Information
Abbreviations
100
A centralized location of health and biomedical terminologies and standards.
What is the Unified Medical Language System (UMLS)?
100
This supports standardized input and understanding of all data elements. Some common data elements are data field, definition, type and format.
What is the data dictionary?
100
This is a method used to identify patients who have been seen or treated in a facility for a particular disease or condition for inclusion in a registry.
What is case finding?
100
A management report of process measures.
What is a dashboard?
100
HIE.
What is Health Information Exchange?
200
If data aggregation is the goal of collecting the data, this is the best choice.
What are classifications?
200
Examples would be: blood pressure of 159/100, a lab result showing bacteria or there being 20 delinquent charts.
What is data?
200
This is a collection of secondary data related to patients with a specific diagnosis, condition, or procedures.
What is a disease registry
200
This is when physicians correct the errors at the time of dictation.
What is front end speech?
200
NLP.
What is Natural Language Processing?
300
This consists of small components of details and is key for clinical terminology.
What is data granularity?
300
Process of extracting from a database or data warehouse large volumes of data to identify relationships or patterns and using that to predict behaviors.
What is data mining?
300
This contains data from multiple facilities in a geographic area.
What is a population-based registry?
300
This is created, gathered and managed by the patient and is different than an EHR.
What is a personal health record?
300
DEEDS.
What is Data Elements for Emergency Departments System?
400
ICD-10-CM, ICD-10-PCS, ICF, ICD-O-3 and DSM-5 are examples of this system.
What are classifications?
400
This includes: accuracy, accessibility, comprehensiveness, consistency, currency, definition, granularity, precision, relevancy and timeliness.
What is the data quality management model?
400
The food and drug administration modernization act of 1997 mandated this and the National Library of Medicine is responsible for the database.
What is clinical trials?
400
When the information is entered into the health record at the time and location of service - can be structured or unstructured data.
What is point-of-care charting?
400
UHDDS.
What is Uniform Hospital Discharge Data Set?
500
Concepts (a specific thought or abstract), Descriptions (human readable representations of concepts, and Relationships (defines the meaning of the concept in which a computer can process) are included in this.
What are SNOMED CTs three main components?
500
This includes: accountability, transparency, integrity, protection, compliance, availability, retention and disposition.
What are AHIMA's 8 Information Governance Principles?
500
This registry contains the following information: care received before hospital (ems), status of patient at time of admission, patients course in hospital, diagnosis and procedure, info on injury, abbreviated injury scale (nature of injury and threat to life by body system - car industry), injury severity scale.
What is a trauma registry?
500
These include: direct exchange, query-based exchange and consumer-mediated exchange.