UHDSS came into the limelight in the 1969 conference of the National Center for health services and research. It was stipulated that short term general hospitals would have to gather information on patient elements. The Federal government later incorporated them into the Medicare and Medicaid programs.
This can be defined as a set of data which provides the least description of a hospital, pertaining its admission and it is recommended when patients are discharged for all hospital stays which are recompensed under Medicare together with Medicaid. There are mostly used to report and record data of inpatients that are under acute care, long-term and short-care in hospitals. Most payers of other health care systems use these data sets for purposes of billing.
In the UHDSS the information that has to be present include; principal diagnosis, diagnosis which are important to the particular hospital episode together with all the relevant procedures. Information regarding the patient, such as the age, gender, race, ethnicity, residence and date of birth are also included. UHDSS are mostly used for the reporting of inpatient data but are also used in non-outpatient systems as well. They are also used in rehabilitation centers, psychiatric centers. Short term hospitals, nursing centers, health home facilities and long term care facilities.
Uniform Ambulatory Care Data Set (UACDS) for outpatient or ambulatory patients
This refers to a standard set of data used for purposes of ambulatory health records. The main purpose of UACDS is to improve the comparison and collation used in ambulatory together with outpatient care systems. These are maintained by Centers for Medicare $ Medicaid Services (CMS). All Ambulatory Care Facilities that are under CMS are required to participate fully.
They get their approval from the National Committee on Vital and Health Statistics. Most of the information is same as what is present in Uniform Hospital Discharge Data Set, however, most of it tries to evaluate and explain the living conditions of the patients. UACDS is yet to be integrated into the federal regulations.
Minimum Data Set (MDS) for long-term care
These are a requirement by law just as Uniform Hospital Discharge Data Sets. They are used in long term care facilities for the purposes of inpatient reporting. They form the basis for an in-depth, comprehensive and deep evaluation and screening of long term care patients. The information is consequently used to create RAPs (Resident Assessment Protocols). MDS apply Resident Assessment and Validation Entry system in their data entry. They systematize and regulate communication regarding patients problems and their respective conditions. The main advantage of MDS is that they make the process of quality monitoring to be easier, less cumbersome, effective and efficient. They are sustained by Centers for Medicare $ Medicaid Services. MDS are incorporated and regulated by federal laws; as such it is a requirement for all Long-term care facilities to participate fully. They were put into effect and enacted in 2009 by the Department of Health and Human Services.
MDS systematizes and categorizes data into several categories (a total of twenty) and every classification set contains a list of choices together with their corresponding responses.
The core health data elements which have been proposed for standardization process among the above data sets include; personal information, date of birth, gender of the patient, race and ethnicity, place of residence, marital status, functional status, principal and primary diagnosis for inpatients, operating physician identification for inpatients, provider identifications for ambulatory, patient expected source of payment, admission dates among other requirements.
Greenberg, Marjorie S. and Judith Miller Jones. "Toward Standardization of Health Information." Journal of AHIMA 68, no.2 (2007): 22-28.
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