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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 don't 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?
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