Across
- 1. Anu manual or electronic notation (or recording) made by a physician or other healthcare professional clinician related to a patient’s medical condition or treatment.
- 4. Criteria determined by Medicare that, if present in a patient’s record, are likely to result in higher quality of care than if they are not present.
- 10. The overall management of the availability, usability, integrity, and security of the data employed in an organization or enterprise.
- 12. A descriptive list of names, definitions, and attributes of data elements to be collected in an information system or database whose purpose is to standardize definitions and ensure consistent use.
- 15. Information that can be translated by a coder into a code.
- 16. The disease or condition that was present on admission, was the principal reason for admission, and received treatment or evaluation during the hospital stay or visit or the reason established after study to be chiefly responsible for occasioning the admission of the patient to the hospital for care.
- 18. Refers to the process of analyzing, assessing, and reconstructing a situation to provide enhanced solutions and outcomes to a problem.
- 19. A question posed to the documenting physician during the patient’s hospital stay.
- 20. An organized collection of data, text, references, or pictures in a standardized format, typically stored in a computer system for multiple applications.
- 24. The acquisition of all the business data and information from potentially multiple, cross-platform sources, such as legacy databases, departmental databases, and online transaction-based databases, and then the warehouse storage of all the data in one consistent format used to analyze data for decision-making purposes.
- 27. A technique that develops scenarios based on how users will use information to assist in developing information systems that support the information requirements.
- 28. Binary, machine-readable data in discrete fields; data able to be processed by the computer.
- 29. Allows for connections between two systems. This connection allows for data initially captured for one purpose to be translated and used for another purpose. One system is identified as the source while the other is the target.
- 30. The process of extracting and analyzing large volumes of data from a database for the purpose of identifying hidden and sometimes subtle relationships or patterns and using those relationships to predict behaviors.
- 31. The extent to which healthcare data are complete, accurate, consistent, and timely; A security principle that keeps information from being modified or otherwise corrupted either maliciously or accidentally.
- 33. The process an organization undertakes that will improve clinical specificity and documentation, which will allow coders to assign more concise disease classification codes.
- 34. A type of database that stores data in predefined tables made up of rows and columns.
- 35. A private or government agency involved in the development of healthcare informatics standards at a national or international level.
Down
- 2. A system consisting of several phases that represent the useful life of a database, including initial study, design, implementation, testing and evaluation, operation, and maintenance and evaluation.
- 3. The accountability framework and decision rights to achieve enterprise information management; the responsibility of executive leadership for developing and driving strategy throughout the organization; encompasses both data governance and information technology governance.
- 5. The average relative weight of all cases treated at a given facility or by a given physician, which reflets the resource intensity or clinical severity of a specific group in relation to the other groups in the classification system; calculated by dividing the sum of the weights of diagnosis-related groups for patients discharged during a given period by the total number of patients discharged.
- 6. The capability of different information systems and software applications to communicate and exchange data.
- 7. Healthcare services based on clinical methods that have been thoroughly tested through controlled, peer-reviewed biomedical studies.
- 8. A database that makes it possible to access data from multiple databases and combine the results into a single query and reporting interface.
- 9. Physicians and clinicians practicing using the seven criteria for documentation: legible, reliable, precise, complete, consistent, clear, and timely.
- 11. The combined practices of HIM, IT, and HI that affect how data and documentation combine to create a single business record for an organization; The definition and structure of data elements and the creation, storage, and transmission of data elements.
- 13. 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.
- 14. Standards developed to support and create structure with data exchanges to support interoperability; the goal of the data interchange standard is to facilitate consistent, accurate, and reproducible capture of clinical data.
- 17. The location from which the data is mapped or to where it is sent.
- 21. The responsibilities and accountabilities associated with managing collecting, viewing, storing, sharing, disclosing, or otherwise making use of personal health information.
- 22. Nonbinary, human-readable data.
- 23. The process of creating an inventory 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, and providing basic security measures for the systems.
- 25. Communication tool for CDI staff to communicate with providers to obtain clinical clarification, provide a documentation alert, get documentation clarification, or ask additional questions regarding documentation.
- 26. A list of recommended data elements with uniform definitions that are relevant for a particular use or are specific to a type of healthcare industry.
- 32. Operating documents that describe the rules and regulations under which a healthcare organization operates.