HINT770 Health care code settings and terminology

HINT 770: Clinical Vocabulary and Reimbursement
Week 2: Creating a Data Dictionary

In the mapping exercise, you mapped diagnoses to different classification systems. As you looked up
the information, you entered text (or a numerical value) into the search engine and a code number
popped up. Behind the scenes, the look-up function is looking at data dictionaries to see what entries
match your search.

There are three parts to this assignment.

Part 1: Evaluating an existing data dictionary. (12 Points)

You are to look at the excerpt from a data dictionary below showing how certain fields are to be formatted. You are to evaluate the dictionary and identify areas where there may be problems in the way the fields would be entered. Include a reason why you think this would be a problem. Enter your
findings in the comment section

Name	First Name, Middle Initial, Last Name (FN, MI, LN)	25
Admission Date	Numeric	6
Discharge Date	Numeric	6
Payment Source	Free Text	20
Principle Diagnosis (ICD-10-CM)	Alpha	6
Procedure (CPT)	Numeric	5

Part 2: Create a mini-data dictionary (35 points)

For this part of the assignment, you will create a mini-data dictionary. Each variable must be defined by the appropriate attributes (listed at the top). Consider the Medical Record Number, for example. Each institution has a different way of assigning an MRN. Some might be alpha-numeric, some just numeric, some might have 6 digits, some might have 8 digits. Assume you have to create a data dictionary that will be used by different facilities who are being merged into one health system. There must be a dictionary that will identify for each of the facilities how the overall organization wants to classify certain patient characteristics. For the variables “Gender at Birth”, “Self-Identified Gender Identity”, “Race”, and “Disposition of Patient”, you must include the allowed values.

For example, if one of the categories were admission type, you might have:
● Emergency admission: 01
● Scheduled admission: 02
● Unscheduled admission: 03
Use the information found in Chapter 14 and the UHDDS Data Set to assist you.

Part 3: Short Answer (17 points)

1. Select one of the fields from Part 2 above. Using the excerpt from the Specifications Manual (Click Here) as a guide, create a similar document using the following headings:

● Field Name:
● Definition of Field:
● Suggested Data Collection Question:
● Format:

○ Length:
○ Type:
○ Occurs:

● Allowable Values:
● Notes for Abstraction:
● Suggested Data Sources:

Patient Name has been done for you.

Field	Field Abbreviation	Type of Entry T: Text AN: Alphanumeric N: number D: Date	Format	Allowed Values (certain categories will have defined entries—such as gender at birth)	Description
Patient Name	NAME	T	Last Name, First Name, Middle Initial LN, FN, MI	Free text	Legal Name of patient. No nicknames.
Medical Record Number
Address
Date of Birth
Gender at Birth
Self-Identified Gender Identity
Race
Disposition of Patient (where they went after discharge)

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