20 Points
Assignment Instructions, Requirements, and Evaluation:

Using the Meaningful Use Stage 2 materials provided in this unit, and the Use Case below, create a Data Dictionary. (Be sure to find the Use Case on the Meaningful Use Stage II materials included in the Week 3 folder. This will explain the use case and provide guidance on the terminologies needed.)

Objective: The EP, EH, or CAH who transitions their patient to another setting of care or provider of care or refers their patient to another provider of care should provide summary care record for each transition of care or referral.
Measure: The EP, EH, or CAH that transitions or refers their patient to another setting of care or provider of care provides a summary of care record for more than 50% of transitions of care and referrals.

Develop a sample data dictionary to include 3-5 data elements derived from a clinical terminology and one data element from another clinical vocabulary source (not from a named clinical terminology standard) for a data set that would address the use case you chose above.
Review the Common Meaningful Use Data Set prior to beginning your data dictionary, this is also included in the Meaningful Use Stage II materials.
Please note: depending on the data element, it may not have a coded value data type and therefore no vocabulary or code set. For example, if the data element is date of birth, the coded value would be date so there is no vocabulary or code set standard to consider.Below is some information that may help answer questions about the assignment:
Construct a data dictionary for the elements in the data set. Include the data element name, data element description/definition, vocabulary or code set standard for the data element if applicable, data type (text, coded values, etc.), data format, and range of values.
Make sure to cite your sources!

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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