Medical Data Management is a systematic introduction to the basic methodology of professional clinical data management. It emphasizes generic methods of medical documentation applicable to such diverse tasks as the electronic patient record, maintaining a clinical trials database, and building a tumor registry. This book is for all students in medical informatics and health information management, and it is ideal for both the undergraduate and the graduate levels. The book also guides professionals in the design and use of clinical information systems in various health care settings. It is an invaluable resource for all health care professionals involved in designing, assessing, adapting, or using clinical data management systems in hospitals, outpatient clinics, study centers, health plans, etc. The book combines a consistent theoretical foundation of medical documentation methods outlining their practical applicability in real clinical data management systems. Two new chapters detail hospital information systems and clinical trials. There is a focus on the international classification of diseases (ICD-9 and -10) systems, as well as a discussion on the difference between the two codes. All chapters feature exercises, bullet points, and a summary to provide the reader with essential points to remember. New to the Third Edition is a comprehensive section comprised of a combined Thesaurus and Glossary which aims to clarify the unclear and sometimes inconsistent terminology surrounding the topic.
Table of Contents
1. What is Medical Data Management About?; 2. Basic Concepts of Clinical Data Management and Coding Systems; 3. Important Medical Coding Systems; 4. Typical Medical Documentation; 5. Utilization of Clinical Data Management Systems; 6. Clinical Data Management: Let's Make a Plan!; 7. Documentation in Hospital Information Systems; 8. Data Management in Clinical Studies; 9. Concluding Remarks; 10. Suggested Further Information; 11. Thesaurus of Medical Documentation