primary data source
The health record is considered a ________________________ because it contains information about a patient that has been documented
... [Show More] by the professionals who provided care or services to that patient.
secondary data source
Data taken from the primary health record and entered into registries and databases are considered a _____________________.
patient-identifiable data
The health record consists entirely of _____________________. In other words, every fact recorded in the record relates to a particular patient.
Registries
______________ are an example of patient-identifiable data on groups of patients.
Aggregate data
Include data on groups of people or patients without identifying any particular patient individually. Secondary data are considered ________________.
statistics on the average length of stay (ALOS)
Examples of aggregate data are _________________________ for patients discharged within a particular diagnosis-related group (DRG).
-facility-specific indexes
-registries, either facility or population based
-other healthcare databases
Secondary data sources consist of ?
disease-oriented databases
Data extracted from health records and entered into _______________ can, for example, help researchers determine the effectiveness of alternate treatment methods, as well as, demonstrate survival rates at different stages of disease.
Internal users of secondary data
___________________ are individuals located within the healthcare facility including medical staff and administrative and management staff.
identify patterns and trends
Secondary data enable these internal users to __________________that are helpful in patient care, long-range planning, budgeting, and bench-marking with other facilities.
External users
________________ of patient data are individuals and institutions outside the facility like state data banks and federal agencies.
aggregate data and not patient-identifiable
The secondary data provided to external users is generally ______________ and not _________________ data.
indexes
The secondary data sources that have been in existence the longest are the ____________ that have been developed within facilities to meet their individual needs.
report from a database
An index is simply a ______________________ that enables health records to be located by diagnosis, procedure, or physician.
handwritten data
Prior to extensive computerization in healthcare, these indexes were kept on cards with ________________.
master patient index (MPI)
The ______________________, which is sometimes called the master person index, contains patient-identifiable data such as name, address, date of birth, dates of hospitalizations or encounters, name of attending physician, and health record number.
quickly retrieve health information
The MPI is an important source of patient health record numbers. These numbers enable the facility to __________________________ for specific patients.
admission, pre-admission, or registration
Most of the information in the MPI is entered into the facility data-base at the time of the _________, _______________, or ___________ process.
disease index
In an acute care setting, the _____________ is a listing in diagnosis code number order for patients discharged from the facility during a particular time period. It is considered patient-identifiable data.
patient's health record number | diagnosis codes
The index always includes the ________________ as well as the __________________ so that records can be retrieved by diagnosis.
non-acute settings
In ________________, the disease index might be generated to reflect patients currently receiving services in the facility.
operation index
The ______________ is similar to the disease index except that it is arranged in numerical order by the patient's procedure code(s), usually using ICD or Current Procedural Terminology (CPT) codes, and the surgeon may be listed in addition to, or instead of, the attending physician.
query the health information system
In many cases, facilities no longer have an actual listing for the diagnosis and operation indexes. Instead, they ___________________ utilizing the diagnosis or procedure code needed.
physician index
The __________________ enables users to retrieve information about a particular physician, including the number of cases seen during a particular time period. As with the disease and operation indexes, facilities generally query the health information system (HIS) to obtain physician data.
case definition
Registries often require more extensive data from the patient record. Each registry must define the cases that are to be included.
This process is called ____________________.
Case finding
__________________ includes the methods used to identify the patients who have been seen and treated in the facility for the particular disease or condition of interest to the registry.
facility-based registry
A registry located within a facility such as a hospital or clinic.
population-based registry
A registry that gathers information from more than one facility within a geographic area such as a state or region.
Aggregate clinical information
_______________________ is needed to improve the diagnosis and treatment of cancer.
Database management systems (DBMS)
______________ are software tools used to store, analyze, modify, and access data.
Relational databases
This model consists of a database with a set of formally described tables, related (linked) to each other by a shared reference. Users can create their own interactive queries.
- conceptual
- logical
- physical
There are three steps to database design, which are?
data modeling
The process of formalizing data requirements and the structure used to organize data is called?
Conceptual Database Design
Assess user requirements and Construct entity relationship diagram are examples of which data model?
Logical Database Design
Select logical data model and map schema and Construct data repository and normalize attributes are examples of which data model?
Physical Database Design
Determine type of storage and Determine access mechanism are examples of which data model?
entity relationship diagram (ERD)
This diagram has three basic graphical symbols.
Object-oriented modeling
This type of modeling is used by computer programmers to develop systems that are analogous to the real world by formalizing concepts such as objects, their functions, and relationships.
Semantic modeling
This type of modeling is used by linguists to represent the meaning of words.
Entity
An __________ can be thought of as a class of objects that exist in the real world and have related properties. They can be a type of person, place, or thing. Which graphical symbols does this represent?
attributes
describe characteristics and are represented as circles. Which graphical symbols does this represent?
relationships
describe associations between entities and are represented with diamonds. Which graphical symbols does this represent?
conceptual modeling
Entity relationship modeling is a type of _______________. Which is abstract and encourage high-level problem structuring; they help establish a common ground for communication between users and developers.
schema mapping
ERDs are converted into tables by a process called ?
cardinality of the relationship
The main rule used to determine table structure is based on the _____________________ (the maximum number of occurrences of each entity that occurrences of other entities can link to).
Normalization
______________________ eliminates errors associated with updates, deletions, and insertions of data into the database. It reduces redundancy and improves data quality. [Show Less]