Imagine you are an HIM Compliance Manager for a large hospital system, and you are responsible for the integration of new clinical data into your existing electronic health record (EHR). During your research of clinical process modeling, you learned about how healthcare data sets and dictionaries are used in hospital settings. For example, hospitals utilize the Uniform Hospital Discharge Data Set (UHDDS) which is considered a core data set for hospital reporting. The UHDDS contains a data dictionary where the principal diagnosis, a data element, is defined along with its allowable value, an ICD-10 CM code.
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