RHIA Prep Domain 1 Section 2

An agreed-upon rule or specification for representing, collecting, exchanging, or using health data consistently.

Data standard

A single defined item of information, such as discharge date, date of birth, or principal diagnosis.

Data element

A centralized collection of definitions, formats, allowable values, and other characteristics for data elements.

Data dictionary

A precise description of the meaning and intended use of a data element.

Data definition

Data that describe other data, such as a field's name, definition, format, source, or allowable values.

Metadata

The process of making data definitions, formats, and collection methods consistent across systems or organizations.

Standardization

Data entered in a predefined, organized format that can be readily searched, sorted, and analyzed.

Structured data

Data that do not follow a predefined data model, such as narrative notes or free-text documentation.

Unstructured data

A defined group of related data elements collected for a particular purpose.

Data set

Uniform Hospital Discharge Data Set; standardized data elements used for hospital inpatient discharge reporting.

UHDDS

Uniform Ambulatory Care Data Set; standardized data elements developed for ambulatory care settings.

UACDS

Minimum Data Set; a standardized resident assessment used in Medicare- and Medicaid-certified long-term care facilities.

MDS

Outcome and Assessment Information Set; standardized assessment data used in Medicare-certified home health care.

OASIS

Healthcare Effectiveness Data and Information Set; standardized performance measures widely used to evaluate health plans.

HEDIS

The ability of different information systems to exchange, interpret, and use health information effectively.

Interoperability

A comprehensive clinical terminology used to represent clinical concepts consistently in electronic health information.

SNOMED CT

The process of linking equivalent data elements, codes, or concepts between different data sets or systems.

Data mapping

The original information system or data set from which data are obtained.

Source system

The destination information system or data set to which mapped data are transferred.

Target system

Data collected directly for the original purpose for which they are being used.

Primary data

Data originally collected for another purpose and later reused for reporting, research, registries, or analysis.

Secondary data

Data used for operational, financial, registration, billing, and

management functions.

Administrative data

Information about a patient's health status, diagnoses, treatments, procedures, and clinical outcomes.

Clinical data

Patient-identifying and descriptive information such as name, date of birth, sex, address, and other characteristics.

Demographic data