| A | B |
|---|
| Classification System | A standardized framework and coding system used to categorize and classify health-related data. |
| Coding System | A structured system used to assign codes to health-related information. |
| Health-Related Data | Data related to health conditions, services, interventions, encounters, or healthcare delivery. |
| Interoperability | The ability of health information to move between systems and be understood consistently. |
| Data Integration | Combining data from different sources or systems so it can be used together. |
| Quality Improvement | Activities that use data to improve healthcare processes, outcomes, and performance. |
| Decision-Making | Using health data and information to guide care, planning, reporting, or management decisions. |
| International Classification of Diseases (ICD) | A classification system used to categorize diseases and related health problems. |
| ICD-10-CA | International Statistical Classification of Diseases and Related Health Problems, 10th Revision, Canada. |
| Canadian Classification of Health Interventions (CCI) | A national classification system for diagnostic, therapeutic, and other healthcare interventions. |
| Systematized Nomenclature of Medicine - Clinical Terms (SNOMED CT) | A clinical terminology used to record patient data in a structured way that supports interoperability and analysis. |
| Nomenclature | A system of names or terms used to label and identify specific medical concepts. |
| Terminology | Terms that belong to a nomenclature and identify specific concepts or entities. |
| Predefined Code | A code already defined within a classification system. |
| Code Combination | A combination of codes or concepts used in a nomenclature system to describe more complex clinical ideas. |
| Medical Concept | A clinical idea, condition, procedure, finding, or other healthcare concept that can be represented by a term or code. |
| Data Abstraction | The extraction of selected clinical, administrative, and demographic data from the patient record. |
| Abstract | A record of selected data from a hospital visit or patient encounter, including clinical, administrative, and demographic information. |
| Patient Encounter | A healthcare interaction or visit between a patient and a provider or organization. |
| Hospital Visit | An encounter in which a patient receives hospital-based healthcare services. |
| Clinical Data | Health information related to diagnoses, investigations, treatments, and patient care. |
| Administrative Data | Information related to healthcare administration, such as physician information, admission and discharge dates, and visit disposition. |
| Demographic Data | Patient-identifying information such as gender, date of birth, postal code, or residence code. |
| Episode of Care | A period or instance of healthcare service provided to a patient. |
| Diagnosis Code | A code assigned to represent a patient’s diagnosis or condition. |
| Intervention Code | A code assigned to represent a healthcare intervention, treatment, or procedure. |
| Database Submission | The process of sending coded abstract information to a database or stakeholder. |
| Abstracting System | A system used to collect, code, organize, group, report, and submit data through abstracts. |
| WinRecs | A Canadian abstracting system produced by Med2020 and used to collect and submit data through abstracts. |
| 3M Abstracting System | An abstracting system used in Canada to support data capture, grouping, reporting, and decision-making. |
| Data Capture | The process of collecting or entering data into a system. |
| Data Grouping | Organizing data into meaningful groups for reporting, analysis, funding, or decision-making. |
| Data Reporting | Submitting or presenting data for organizational, regulatory, funding, or planning purposes. |
| Data Transformation | Changing data into a different form or structure so it can be used, grouped, or reported. |
| Efficient Retrieval | The ability to locate and access needed data quickly. |
| Inpatient Module | An abstracting system module focused on patients admitted to hospital for a period of time. |
| Clinical Module | An abstracting system module focused on diagnoses, lab results, examinations, and treatment plans. |
| Ambulatory Care Services Module | An abstracting system module focused on services for patients who do not require an overnight stay. |
| Outpatient Consultation | A healthcare consultation for a patient who is not admitted overnight. |
| Minor Procedure | A less complex procedure often performed without an overnight hospital stay. |
| Concurrent Review | A review process that occurs while care or documentation is still in progress. |
| Chart Maintenance | An abstracting system function that supports management and correction of chart data. |
| Clinical Terminology | A structured set of terms used to record clinical information. |
| Input Terminology | Terminology used by providers while entering symptoms, diagnoses, procedures, or other clinical data. |
| Statistics | Numerical data used for analysis, reporting, planning, or monitoring trends. |
| Physician Data Entry | The process of a physician or provider entering patient conditions or diagnoses into an electronic record. |
| Care Provider | A healthcare professional who provides patient care and may enter information into the health record. |
| Structured Clinical Data | Clinical information recorded in a consistent format that supports searching, reporting, and analysis. |
| Decision Support | Use of electronic information to support healthcare decisions. |
| Information Sharing | The exchange of health information between authorized users or systems. |
| Analytics | The analysis of data to identify patterns, support reporting, and guide decisions. |
| Code Accuracy Review | Review of generated or assigned codes to confirm they accurately represent the patient encounter. |
| Problem List | A structured list of a patient's health problems or diagnoses in an electronic record. |
| Output | Information produced by a system, such as codes used for statistics or billing. |
| Data Standardization | Using consistent codes, terms, and structures so data can be recorded, exchanged, and analyzed reliably. |
| Common Characteristics | Shared features used to group concepts in a classification system. |
| Shared Attributes | Properties used to group or categorize information in a classification system. |
