20 Points
Assignment Instructions, Requirements, and Evaluation:
You are not expected to include specific ranges of codes (data dictionary range of values). For example, if you useSNOMED CT, the clinical finding hierarchy contains the range of codes for diseases and findings which would be the type of content found on a problem list. Thus, if SNOMED CT is one of your vocabulary standards listed in your data dictionary, you would note clinical finding hierarchy for the range of values.
Here are two additional resources that may be helpful as you begin to construct your data dictionary:
Data Elements for EHR Documentation
http://library.ahima.org/xpedio/groups/public/documents/ahima/bok1_034460.hcsp?dDocName=bok1_034460
Health Data Analysis Toolkit
http://library.ahima.org/xpedio/groups/public/documents/ahima/bok1_048618.pdf
Example Structure for Data Dictionary (Feel free to use another structure, this is just an example):
Data Dictionary
X= no code necessary
Data Element Name |
Data element definition |
Vocabulary/code set standard |
Data type |
Data format |
Range of values |
Patient Demographic Information |
—————- |
—————— |
————— |
—————– |
—————— |
Last Name |
Full legal last name of patient |
X |
Alpha |
abcdefghijklm |
X |
Full First Name |
Full legal first name of patient |
X |
Alpha |
abcdefghijklm |
X |
Medical Record Number |
The unique number assigned to the patient |
X |
Alphanumeric |
Must start with letter and not more than 6 number |
A123456 |
Clinical Information |
————— |
—————— |
—————— |
—————— |
—————— |
Past Medical History |
Complete medical history of patient |
SNOMED CT |
Coded |
9 numbers |
70753007 |
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