In healthcare, data sets serve two purposes. The first purpose is to identify data elements to be collected about each patient. The second is to _____.
provide uniform data definitions
Which of the following is NOT a characteristic of the common healthcare data sets such as UHDDS and UACDS?
They provide a complete and exhaustive list of data elements that must be collected.
The home health prospective payment system uses the _____ data set for patient assessments.
OASIS
A health information technician has been charged with the responsibility of designing a data collection form to be used on admission of a patient to the acute care hospital in which she works. The first resource that she should use is
UHDDS
A notation for a diabetic patient in a physician note reads: "FBS 110 mg%, urine sugar, no acetone." In which part of a POMR progress note would this notation be written?
Objective
A notation for a hypertensive patient in a physician ambulatory care progress note reads: "Continue with Diuril, 500 mgs once daily. Return visit in 2 weeks." In which part of a POMR progress note would this notation be written?
Plan
A critical early step in designing an EHR is to develop a(n)________ in which the characteristics of each data element are defined.
data dictionary
In long-term care, the resident's care plan is based on data collected in the ______.
MDS Version 2.0
Which of the following indexes and databases includes patient-identifiable information?
Master patient/population index
Once hospital discharge abstract systems were developed and their ability to provide comparative data to hospitals was established, it became necessary to develop ______.
