To process a request for information, you need to access the correct patient for processing. A master patient index (MPI) is a database of key information by patient, registered by a health care organization. If the MPI is used by a system, it is referred to as an enterprise master patient index (EMPI). Within the MPI/EMPI, sufficient information is retained to identify a patient, but it does not contain all information about a patient. The database uses algorithms to determine if a patient is already in the system and to avoid the creation of a duplicate. For each data element, there is a data dictionary with a definition, format for input, and system source of information.
Using the MPI/EMPI Data Dictionary, also listed below,
Review each patient record in your packet.
Complete and submit the Master Patient Index Template for your assigned packet, also listed below.
Note: You are only abstracting the information from one patient encounter.
Complete the data dictionary information for the patients in your packet. The patient files are from the V-Lab patient records, and you are only abstracting the information from one patient encounter.
IP Encounter Report
Admission Information – Hospital Account/Patient Record
Arrival Date/Time: None Admit Date/Time: 08/20/2013 6:00 AM IP Adm. Date/Time: 08/20/2013 6:00 AM
Admission Type: Elective Point of Origin: Clinic Or Physician Office Admit Category: None
Means of Arrival: Walk In Primary Service: Cardiology Secondary Service: None
Transfer Source: None Service Area: The Children’s Hospital
(Sa)
Unit: Cpcu
Admit Provider: Mitchell, Max B. Attending Provider: Truong, Uyen T. Referring Provider: None
Discharge Information – Hospital Account/Patient Record
Discharge Date/Time Discharge Disposition Discharge Destination Discharge Provider Unit
08/26/2013 12:34 PM Dc To Home Or Self Care
(Routine Disch)
Home Truong, Uyen T. Cpcu
ED Arrival Information
ED Disposition
None
Hospital Problems Reviewed: 6/28/2012 7:39 AM by Kaufholz, Charlotte D.
None
Non-Hospital Problems Reviewed: 6/28/2012 7:39 AM by Kaufholz, Charlotte D.
Codes Priority Class Noted – Resolved
Single Ventricle 745.3 Unknown – Present
Entered by Dumond, Alison
M.
severe pulmonary stenosis 746.9 1/20/2010 – Present
Entered by Dumond, Alison
M.
DOLV (Double Outlet Left Ventricle) 745.19 2/17/2010 – Present
Entered by Bartakian, Sergio
Bilateral SVC’s 747.49 3/3/2010 – Present
Entered by Ivy, D. Dunbar
MAPCA (major aortopulmonary collaterals) without PA-VSD 747.39,
747.29
3/9/2013 – Present
Entered by Villavicencio,
Karrie L.
RESOLVED: Double Outlet Right Ventricle/Mitral Atresia/Pulmonary
Stenosis/Left SVC
745.11 – 2/17/2010
Entered by Mackie, Sara M.
Resolved by Bartakian,
Sergio
RESOLVED: Chylothorax 457.8 4/13/2010 – 2/21/2012
Entered and resolved by
Dumond, Alison M.
Discharge Summaries – All Notes
Cardiology Inpatient Discharge Summary
Patient Name:
Admit: 8/20/2013
Discharge: 8/26/2013
Attending: Uyen Truong, MD
Primary Cardiologist:Karrie Villavicencio, MD
CT Surgeon: Dr. Max Mitchell
PCP: Jeremy D. Parker, M.D.
Diagnoses:
Principal/Final Diagnosis: Single ventricle (left) with tricuspid valve atresia, L-malposed great vessels,
(MR # Printed by [103311] at 10/11/13 9:47 AM Page 1
Filed: 8/27/2013 11:38 AM Note Time: 8/26/2013 10:00 AM
Related Notes: Original Note by Tiernan, Kendra D. filed at 8/26/2013 2:41 PM
Discharge Summaries signed by Truong, Uyen T. at 8/27/2013 11:38 AM
Author: Truong, Uyen T. Service: Cardiology Author Type: Physician
Patient not seen in ED
First: Jerry
Middle:
Last: Lee
DOB: 4/8/10
Address: 538 Happy Malls Drive
Paramus, NJ 07653
Phone: 201-834-1313
MS:
MRN: 00-08-56-65-00
G: Male
R: Asian
SSN#: 234-55-6600
Adm:8/20/2013, D/C:8/26/2013
Site: Wilkes-Barre Hospital
IP Encounter Report MRN:
DOB: Sex: M
Adm:8/20/2013, D/C:8/26/2013
Discharge Summaries – All Notes (continued)
severe pulmonary valve stenosis, bilateral SVC.
History of Present Illness:
is a 3 year old male with complex cyanotic congenital heart disease consisting of a single ventricle, L-
malposition of the arteries,
MPI/EMPI Data Dictionary
Data Element Title in System
Full Data Element Title
Definition/Description
Format
A-Alpha
N-Numeric
M-Month
D-Day
Y-Year
System Source of information
Last Name
Last Name
Legal name that matches with identification
AAAAAAAAAAAAAAAA
Registration System
First Name
First Name
Full name, not nicknames or abbreviation
AAAAAAAAAAAAAAAA
Registration System
MI
Middle Initial
A
Registration System
MRN
Medical Record Number
The unique medical record number associated with all patient medical information. Leading zeroes included.
NN-NN-NN-NN-NN
Registration System
Street Address
Registration System
City
City
AAAAAAAAAAAAAAAA
Registration System
ST
State
Official State abbreviation [Add]
AA
Registration System
Zip Code
NNNNN-NNNN
Registration System
Telephone # (Cell)
Telephone Number
Area code and telephone number for cell telephone.
NNN-NNN-NNNN
Registration System
Telephone # (Other)
Area code and telephone number for other telephone.
NNN-NNN-NNNN
Registration System
MS
Marital Status Types
1: Presently Married
2: Widowed
3: Divorced
4: Separated
5: Never married/annulled
6: Prefers not to answer
N
Registration System
DOB
Date of Birth
MM/DD/YYYY
Registration System
G
Gender
1: Female
2: Male
3: Transgender
4: Other
5: Prefer not to say
NN
Registration System
R
Race
1:
American Indian or Alaska Native:
(Links to an external site.)
A person having origins in any of the original peoples of North and South America (including Central America), and who maintains tribal affiliation or community attachment.
2:
Asian:
(Links to an external site.)
A person having origins in any of the original peoples of the Far East, Southeast Asia, or the Indian subcontinent, including, for example, Cambodia, China, India, Japan, Korea, Malaysia, Pakistan, the Philippine Islands, Thailand, and Vietnam.
3:
Black or African American:
(Links to an external site.)
A person having origins in any of the black racial groups of Africa. Terms such as “Haitian” or “Negro” can be used in addition to “Black or African American.”
4:
Native Hawaiian or Other Pacific: Islander:
(Links to an external site.)
A person having origins in any of the original peoples of Hawaii, Guam, Samoa, or other Pacific Islands.
5:
White:
(Links to an external site.)
A person having origins in any of the original peoples of Europe, the Middle East, or North Africa.
6: Hispanic or Latino: A person of Cuban, Mexican, Puerto Rican, South or Central American, or other Spanish culture or origin, regardless of race. The term, “Spanish origin”, can be used in addition to “Hispanic or Latino”.
NN
SSN#
Social Security Number
Social Security Number
NNN-NN-NNNN
Registration System
Site
Site where patient was seen or registered
Registration System
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