You are developing a complete data dictionary for your facility. Which of the following resources will be most helpful in providing standard…

The Uniform Hospital Discharge Data Set (UHDDS) is the most appropriate resource. It was established by the U.S. Department of Health, Education, and Welfare to create a minimum, common core of data elements for all hospital discharges. It provides standardized definitions for patient-specific data items (e.g., principal diagnosis, principal procedure, other significant procedures) that are routinely collected by acute care hospitals. This standardization is essential for building a reliable and comparable data dictionary, ensuring that data elements are defined and used consistently across the facility and when reporting to external agencies.

A. The Minimum Data Set (MDS) is a standardized assessment tool used for residents in Medicare/Medicaid-certified long-term care facilities, not acute care hospitals.

C. The Conditions of Participation (CoP) are broad federal regulations that facilities must meet to participate in Medicare/Medicaid, but they do not provide a specific list of data elements with standard definitions for a data dictionary.

D. The Federal Register is the official journal for publishing federal agency rules and notices. While it would contain the final rule for the UHDDS, it is the publication vehicle, not the data set standard itself.

1. Oachs

P. K.

& Watters

A. J. (Eds.). (2020). Health Information Management: Concepts

Principles

and Practice (6th ed.). AHIMA Press. In Chapter 5

"Healthcare Data Sets

" the text explicitly states

"The UHDDS is a required data set for acute care hospitals that are Medicare providers... The UHDDS definitions are used by hospitals to report inpatient data elements in a standardized manner." (p. 123).

2. National Center for Health Statistics (NCHS). (1985

July 31). Uniform Hospital Discharge Data Set. Centers for Disease Control and Prevention. The official NCHS page details the purpose of UHDDS as providing "a minimum basic data set... for the collection of uniform information on hospital discharges" and provides the list of data items with their definitions. (Section: "Content").

3. Sayles

N. B.

& Trawick

M. A. (2021). Health Information Management Technology: An Applied Approach (6th ed.). AHIMA Press. Chapter 4

"Data Content and Structure

" describes the UHDDS as the standard for collecting data for Medicare and Medicaid programs in the acute care inpatient setting. (p. 98).