3-1 Activity: Data Dictionary Development

3-1 Activity: Data Dictionary Development
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3-1 Activity: Data Dictionary Development
Categories in the Data Dictionary Template
HIM 350 Communications and TechnologiesModule Three Data Dictionary Template
Table Field Datatype Description and/or Calculation
PATIENT DOB Date The birthdate for the patient
AGE Integer The age of the patient
NAME Varchar(64) The official name of the patient
NEXT_OF_KIN Varchar(64) The occupation of the patient
DIAGNOSIS DIAGNOSIS_CODE Varchar(64) The code for the patient’s diagnosis
PRINCIPAL_DIAGNOSIS Varchar(64) Diagnosis of the patient’s primary condition
SECONDARY_DIAGNOSIS Varchar(64) Diagnosis of the patient’s underlying and secondary conditions
DIAGNOSIS_PROCEDURE Varchar(64) The procedure the physician undertook in the primary and secondary diagnosis
ENCOUNTER ADMIT_TIMESTAMP Date The admission date and time for a patient’s visit
LENGTH_OF_STAY Integer The length of stay at the hospital
INPATIENT_SERVICE_DAYS Integer The number of days taken during treatment
DISCHARGE_INSTRUCTIONS Varchar(64) The instructions for the patient at the time of discharge
SPECIAL_INSTRUCTIONS Varchar(64) The special instructions for the patient during treatment
ATTENDING_PHYSICIAN Varchar(64) The name of the physician responsible for the patient
     
MEDICATION NAME Varchar(64) The name of the antibiotic given
DOSE Integer The duration and quantity of medication intake
MEDICATION_ROUTE Varchar(64) The process of delivering the medication into the patient’s system
SPECIAL_INSTRUCTIONS Varchar(64) The special instructions that accompany the patient’s self-medication
PROCEDURE PROCEDURE_ID Integer A unique ID for the procedure
PRINCIPAL_PROCEDURE Varchar(64) The primary procedures that contribute to the patient’s treatment
SECONDARY_PROCEDURES Varchar(64) The secondary procedures that contribute to the patient’s treatment
FOLLOW_UP Varchar(64) The instructions that will provide patient recovery information away from the facility
VITAL_SIGN TEMPERATURE Integer Patient’s temperature for determination of present infection
REFLEXES Varchar(64) The reaction of the patient’s reflexes
EXTREMITIES Varchar(64) The condition of the patient’s body extremities
IMPRESSION Varchar(64) The overall information derived from the analysis of the vital features of the patient
LAB COLLECT_TIMESTAMP Date The date and time the specimen was collected
TYPE_OF_TEST Varchar(64) The type of test to aid in diagnosis
SPECIMEN Varchar(64) The type of specimen from the patient
SOURCE_OF_SPECIMEN Varchar(64) The location and point of specimen collection on the patient’s body
COMORBIDITY/ PAST MEDICAL HISTORY NAME Varchar(64) Patient’s past medical condition
PREVIOUS_PROCEDURES Varchar(64) Previous surgical procedures for the patient
PRE_EXISTING_CONDITIONS Varchar(64) The patient’s pre-existing condition that requires consideration
FAMILY_MEDICAL_HISTORY Varchar(64) The medical history associated with potential diagnosis
Industry Standards
One industry standard in healthcare is providing quality care that also meets high standards.

I applied the standards by including all the elements that are crucial in accountable healthcare that guarantees the well-being of the patients (Joint Commission, 2017).
Relevance to Providers
The significant content for the providers would be the laboratory and medication entries. On the other hand, the content useful for exchange is the diagnosis entries. The concern of providers is the financial element as well as the quality of the service in the healthcare facility (Joint Commission, 2017). The three contents and their entries provide concise information on quality and cost of healthcare
Master Patient Index (MPI)
MPI creates the link that is useful in tracing the patient to a given organization across healthcare settings.
References
Joint Commission, (2017), Specifications Manual for Joint Commission National Quality Measures (v2017A), Joint Commission