Create a Data Dictionary Entry for a new Data Element Operative Procedures

According to Table 1.1. on the next page the Admission Summary sheet at Valley View General is already capturing data on Admitting Diagnosis. But they dont have a data dictionary entry. As a newly graduate HIM student you have been asked to create a NEW corresponding data dictionary element to describe this data by filing in the form below.

Look at the data field definitions in Table 1-1 for Admitting Diagnosis. Use the format types in Table 1-2 to help you understand the data dictionary entries. Allowable range, access level and edits have already been completed for you and these should not be changed. Be sure your definition includes: at least three sources (i.e. where this data would be found on the chart and/or which department would chart this data.).

Here is a description of some of the other fields in this form that you need to fill in:

Synonyms are other names this data element might be called on the chart.

Responsibility what department (s) is responsible for entering this data correctly at point of care?

Update authority which department(s) have the ability to update this data?

Complete this form:

Field Name
Description
Synonyms
Source
Format Type
Size
Allowable Range	N/A
Access Level	Based on facility policy
Edits	N/A
Responsibility
Update Authority

Use these tables complete the table above.

Table 1-1 Data field definitions for data on current Admission Summary Sheet at Valley General Hospital:

Field Name	Description	Source	Format Type	Size	Example of Data
MRN	Unique patient identifier assigned at time of first admission or encounter	Registration	Numeric	12	248674
FNAME	Patients first name	Registration	Alphabetic	15	Jane
LNAME	Patients last name	Registration	Alphabetic	20	Green
Room	Patients room & bed assignment	Admitting	Alphanumeric	15	ICU-B
Admitting Diagnosis	Admitting Physicians stated reason for admitting the patient. The admitting diagnosis does not change.	H&P	Alphabetic	250	Chest Pain
Principal Diagnosis	Condition established after study to be chiefly responsible for the patients admission	Discharge Summary, Operative Report, Pathology Report	Alphanumeric	250	Myocardial Infarction
Secondary Diagnoses	Other conditions that effected the patients overall treatment or length of stay in the hospital.	H&P	Alphanumeric	250	Diabetes, Asthma
Operative Procedures	Date and Type of Procedure that was done during the Patients Admission	Operative Notes, Discharge Summary	Alphanumeric	250	Inserted cardiac stent on: 09/26/10

Table 1-2 Format Types for Data Dictionary entries:

Field Name	Description	Examples
Alphabetic	Letters of the Alphabet only	Sam
Alphanumeric	Alphabetic letters, numbers, characters	Addresses, phone numbers
Text	Character data, free text with length not limited	CHF
Integer	Number used for calculations	22
Decimal	Number with whole and decimal part	15.20
Character	Special symbols	$, #, +, *
Date	Calendar day & month, various date formats	02/12/11
Time	Represents hours, minutes, seconds	10:22:20
Yes/No	Used for checkboxes	Y/N
Lookup Table	Selecting this option allows the data to be selected from another table via a wizard that pops up.	TX, FL