Version 0.1 draft Prepared by Heather Grain

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Software Requirements
Specification
Part 1: System Functions
GeHCO Vision - ICD
Training Simulator
Global eHealth Collaborative
Not For Profit
Contact info@gehco.org
0413 155 105
Software Requirements Specification for GeHCo Vision - ICD Training Simulator Draft 0.05
Contents
1
System Features ..................................................................................................................... 3
2
Administrational Accounts Administration Functions .............................................................. 4
3
4
5
2.1
Login to system ................................................................................................................ 4
2.2
Update my Profile ............................................................................................................. 5
2.3
Organisation Registration ................................................................................................ 6
2.4
Course Profile ................................................................................................................... 7
2.5
Coding Category .............................................................................................................. 8
2.6
Student Administration ..................................................................................................... 8
EMR Repository..................................................................................................................... 10
3.1
Add a Case ..................................................................................................................... 10
3.2
Add pages ...................................................................................................................... 11
Maintain a Case ..................................................................................................................... 11
4.1
Description...................................................................................................................... 11
4.2
Priority ............................................................................................................................ 11
4.3
Stimulus and Response Sequences .............................................................................. 11
4.4
Functional Requirements ............................................................................................... 12
Code System Repository ....................................................................................................... 12
5.1
6
7
8
9
Add Answer / Feedback ................................................................................................. 12
Hospital System Simulation ................................................................................................... 13
6.1
Patient Index .................................................................................................................. 13
6.2
Display cases for coding ................................................................................................ 14
Clinical Coding Simulation ..................................................................................................... 15
7.1
View Record ................................................................................................................... 15
7.2
Enter Codes ................................................................................................................... 15
7.3
DRG Information ............................................................................................................ 16
7.4
Coding Feedback ........................................................................................................... 17
Reporting and Discovery ....................................................................................................... 17
8.1
Student Results Display ................................................................................................. 17
8.2
Cohort Results ................................................................................................................ 18
8.3
Result Summary ............................................................................................................. 19
8.4
Other Reports ................................................................................................................. 19
Other Non-functional Requirements...................................................................................... 21
9.1
Performance Requirements ........................................................................................... 21
9.2
Safety Requirements...................................................................................................... 21
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Software Requirements Specification for GeHCo Vision - ICD Training Simulator Draft 0.05
9.3
Security Requirements ................................................................................................... 21
9.4
Software Quality Attributes ............................................................................................ 21
9.5
Business Rules............................................................................................................... 22
10
Glossary ............................................................................................................................. 23
Revision History
Date
Version ID
Status
Author
12 July
2015
V0.01
Initial rough draft
Heather Grain
20 July
2015
V0.02
Technical review comments added
Heather Grain
17
August
2015
V0.03
Comments received from community and coders
Heather Grain
20th
August
2015
V0.04
Updated after additional late comments received
Heather Grain
14th
March
2016
V0.05
Updated reflecting industry comments More
detailed specification of functionality and data
required
Heather Grain
Shared with Victorian community
Copyright 2016 Global eHealth Collaborative
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Software Requirements Specification for GeHCo Vision - ICD Training Simulator Draft 0.05
1 System Features
This document is part 2 of a series of documents describing GeHCo Vision ICD coder training
simulator.
Part 1: System Outline
Part 2: System Features
Part 3: Data Specification
Part 4: Governance and Management
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2 Administrational Accounts Administration Functions
2.1 Login to system
2.1.1 Description
Control of access to the system is required, according to the type of user. This functionality
should include automated request for a new password, or request for username.
2.1.2 Priority
This feature is required for the initial test of the system (Priority 1)
2.1.3 Stimulus and Response Sequences
This section defines 'normal' and 'abnormal' processing requirements. This functionality begins
when a user runs the system.
The result of successful receipt of username and password is to offer the main menu according
to the user type.
Role
My profile
Organisation
Admin
Course Profile
Admin
Student Admin
EMR repository
PMI
Coding
Results
Reports
System
Administrator
X
X
Organisation
Administrator
X
X
Educator /
Mentor
X
Student
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
If username and password do not match those in the User Registration File
Display message " "the username and password entered do not match those in our user
register, please try again (you have 3 tries) or request your username or password to be
forwarded to you".
Offer: Request User Name
Offer: Request Password
Offer: Try again (add 1 to the number of tries)
If tries = 3 - display the message "you have tried 3 times and have not entered a known
username and password. Please request your username or password or contact
GeHCo to register - provide email for contact.
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2.1.4 Functional Requirements
Requirement ID
Function
REQ-01.01
Request username and password
REQ-01.02
Retrieve user details from the user registration file.
REQ-01.03
When username/password confirmed go to menu as defined in 4.1.3
according to the user type.
REQ-01.04
Ability to request existing username / password
2.2 Update my Profile
2.2.1 Description
Users and System Administrator may update details for mentors tutors and students. These
details are simple identifying information managed by the user including password.
2.2.2 Priority
This feature is required for the initial test of the system (Priority 1)
2.2.3 Stimulus and Response Sequences
This section defines 'normal' and 'abnormal' processing requirements. This functionality begins
when a user runs the system.
The user selects My Profile from the menu when they login.
The user may save changes made or exit without change.
Changes are time stamped and the previous identifying information retained in the system
history.
When completed the system should return the user to the main menu.
2.2.4 Functional Requirements
Requirement ID
Function
REQ-02-01
Display current identifying data (see definition in the Other Requirements
Data Specification)
REQ-02-02
User may change details
REQ-02-03
User saves or exits without saving
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2.3 Organisation Registration
2.3.1 Description
Each organisation using or contributing to GeHCo Vision must be identified, contact details and
membership status must be recorded. This information is intended to be entered initially by a
GeHCo Vision system administrator. The result of entering this information should be to send
the contact a user name and password.
Organisations must be able to add, modify and delete profile information associated with their
organisation.
2.3.2 Priority
This feature is required for the initial test of the system (Priority 1)
2.3.3 Stimulus and Response Sequences
This feature is instituted by selection of Organisation Administration from the menu.
A save action will
- store a new entry in the Organisation Registration file and User Registration with the
effective date of the date/time of the transaction
- if a prior entry existed update the end date of that entry to the date/time of the
transaction.
Only one organisation registration may be current (have a blank end date) at any given point in
time.
If a new organisation or a change of the contact email - send an email confirming and providing
a new username and password for the user.
When complete the system should return to the main menu.
2.3.4 Functional Requirements
Requirement ID
Function
REQ-03-01
Display blank organisation registration screen
REQ-03-02
When organisation ID entered - check organisation information file
- if the ID exists, display existing information.
- else display question "Organisation ID does not exist - new entry"
If Yes, allocate a new organisation ID and allow user to enter data
required for an organisation registration
REQ-03-03
Save - store the information recorded in the organisation registration fields
with a start date/time of the transaction date/time.
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2.4 Course Profile
2.4.1 Description
An education provider or organisation or individual may establish a profile/s used for the
students/coders. This profile is the set up for operation of the system and automates the cases
put forward for coding to the student or coder. A Course Profile represents a set of instructions
which are used to determine the type, number and rules to be applied for students in this group
2.4.2 Priority
This feature is required for the initial test of the system (Priority 2)
2.4.3 Stimulus and Response Sequences
This feature is instituted by selection of Course Profile Administration from the menu.
A save action will
- store a new entry in the Course Profile Information file with the effective date of the
date/time of the transaction
- if a prior entry with the same identifier exists update the end date of that entry to the
date/time of the transaction.
Course Categories - will go to the course profile function (4.5) and allow entry and maintenance
of functionality required to run the course.
Exit will return to the main menu.
Only one Course Profile registration ID entry may be current (have a blank end date) at any
given point in time.
If a new Course Profile is entered (new ID created) or a change made - send an email to the
user confirming the change.
If a Course Profile is selected and the user is a tutor/mentor they may select student results (4.)
option from this screen.
2.4.4 Functional Requirements
Requirement ID
Function
REQ-04-01
Display blank Course Profile information screen
REQ-04-02
When Course Profile ID is entered - check the Course Profile information
file
- if the ID exists, display existing information.
- else display question "Corhort ID does not exist - new entry" If
Yes, allocate a new organisation ID and allow user to enter data
required for an organisation registration, if Display - display all
Course Profiles current (those with an empty end date) for this
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organisation
REQ-04-03
Display all Course Profiles - allow the user to select a Course Profile which will display that Course Profile information OR return to (REQ-04-01)
REQ-04-04
Save - store the information recorded in the Course Profile information
fields with a start date/time of the transaction date/time.
2.5 Coding Category
2.5.1 Description
For each coding profile specification of one or more groups of case selection and sequence
information is required. The Coding Category information in conjunction with the Course Profile
are used to create and maintain information about how the cases are to be presented and
results processed.
2.5.2 Priority
This feature is required for the initial test of the system (Priority 1)
2.5.3 Stimulus and Response Sequences
This feature is instituted by selection of Student Administration in the main menu.
A save action will
- store a new or updated coding category with the date of the transaction and return to
course profile (4.4).
Exit will return to the main menu.
2.5.4 Functional Requirements
Requirement ID
Function
REQ-05-01
Display existing coding category information if it exists. Allow the user to
modify existing or add new category information.
2.6 Student Administration
2.6.1 Description
This functionality supports the entry and maintenance of student details, including establishing
Profile information. Students/Coders are 'enrolled' in one or more Course Profiles which
determine the set of codes which they are given to complete and if there are groups of codes
required these will be presented in the sequence defined in the Course Profile instructions.
Automatic import of student lists should be accepted.
2.6.2 Priority
This feature is required for the initial test of the system (Priority 1)
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2.6.3 Stimulus and Response Sequences
This feature is instituted by selection of Student Administration in the main menu.
A save action will
- store a new entry in the Student / Coder Register file with the effective date of the
date/time of the transaction
- if a prior entry existed update the end date of that entry to the date/time of the
transaction.
Only one student registration (unique student ID) may be current (have a blank end date) at any
given point in time.
If a new student ID is established - send an email confirming and providing a new username
and password for the student/coder.
A Display Results action will retain the currently selected student and display their result
information (described in 4.7)
2.6.4 Functional Requirements
Requirement ID
Function
REQ-06-01
Display blank Student/Coder Register Screen
REQ-06-02
When student/coder ID entered - check student/coder registration file
- if the ID exists, display existing information.
- else display question "Student/Coder ID does not exist - new
entry" If Yes, allocate a new organisation ID and allow user to
enter data required for an organisation registration.
-if Display - display all students current (those with an empty end
date) for this organisation (the organisation is known through the
current user registration information.
REQ-06-03
Save - store the information recorded in the student/coder registration
fields with a start date/time of the transaction date/time.
REQ-06-04
Display results - if all students current are displayed the user can select
one of these students and request display of results (4.6)
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3 EMR Repository
3.1 Add a Case
3.1.1 Description
This function allows any user to enter a case to be added to the EMR repository. There are
several stages to this process.
- enter the new case (including case information, pages of the case, answers and feedback) described here
- when the case is reviewed GeHCo Vision metadata will be recorded to support the
functionality required in the EMR repository and coding process. This process will also review
and where necessary update the record pages to ensure privacy is maintained, and the record
will be associated with a GeHCo patient and episode record. (4.9)
- when accepted by the governance process the case status will be changed to release it to the
EMR repository for active inclusion in the coding process. (4.9)
3.1.2 Priority
This feature is required for the initial test of the system (Priority 2) These features can initially be
handled manually though the data requirement and governance process are Priority 1.
3.1.3 Stimulus and Response Sequences
This feature is instituted by selection of EMR repository/ Add a new case menu selection.
A save, add pages or add answers/feedback action will:
- store will add a new entry in the EMR repository file with a new date of update of the
transaction date proceed back to the EMR repository main menu
Add pages will add a new entry in the EMR repository file information with a new date of
update (transaction date) and proceed to add pages function.
Add answers/feedback will add a new entry in the EMR repository file information with a
new data of update (transaction date) and proceed to add answers/feedback function.
An exit action will return to the EMR Repository main menu.
3.1.4 Functional Requirements
Requirement ID
Function
REQ-08-01
Establish a case identifier and display metadata collection details for
cases.
All new cases have a status of - to be approved.
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3.2 Add pages
3.2.1 Description
This function allows the user to submit a page, or pages of information into the EHR repository.
Each page is attached to a case (episode of care).
3.2.2 Priority
This feature is required for the initial test of the system (Priority 2) These features can initially be
handled manually though the data requirement and governance process are Priority 1.
3.2.3 Stimulus and Response Sequences
This feature is instituted by selection of add page from the Add Case function (4.8).
A save action will:
- store the page including relevant metadata such as page type (e.g. discharge
summary, laboratory report, progress note) associated with a specific unique case.
An exit action will return to the Maintain a Case menu for this case.
3.2.4 Functional Requirements
Requirement ID
Function
REQ-09-01
Create unique identification for each page and the metadata associated
with the page - this may include submission of a document file or a free
text screen in which the user may enter information as in an EMR. In the
future the EMR functionality will be provided by the GeHCo Vision EMR
simulator.
4 Maintain a Case
4.1 Description
This function allows System or GeHCo Administrator to update case details, pages and
answers.
4.2 Priority
This feature is required for the initial [A1]test of the system (Priority 2) These features can initially
be handled manually though the data requirement and governance process are Priority 1.
4.3 Stimulus and Response Sequences
This feature is instituted by selection of EMR repository maintenance (which is found under
EMR repository menu).
A save action will:
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- update the existing EMR repository file with a new date of update of the transaction
date proceed back to the EMR repository main menu
An exit action from the search or the update screen will return to the EMR Repository main
menu without saving information.
Note: a case cannot have a release status without having a patient and at least one answer
assigned.
4.4 Functional Requirements
Requirement ID
Function
REQ-11-01
Search or browse for the case by status, by case ID, by other metadata
REQ-11-02
Select a case from the search results provided
REQ-11-03
Display case details and show the title of pages entered and
answer/feedback
REQ-11-04
Allow update of these details, including update of status, answers etc.
5 Code System Repository
5.1 Add Answer / Feedback
5.1.1 Description
This function allows any user to enter code answers, feedback and queries associated with a
specific case and code system/version in the EMR repository. Note: answers are specific to a
code system/version and therefore a single case may have more than one set of
answer/feedback.
5.1.2 Priority
This feature would be beneficial for the initial test of the system (Priority 2) These features can
initially be handled manually though the data requirement and governance process are Priority
1.
5.1.3 Stimulus and Response Sequences
This feature is instituted by selection of EMR repository/ Add answer/feedback menu selection.
A save action will:
- store will add a new entry in the Answers and Feedback file associated with a specific
case in the EMR repository file with a new date of update of the transaction date and
return to the
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Add pages will add a new entry in the EMR repository file information with a new date of
update (transaction date) and proceed to add pages function.
Add answers/feedback will add a new entry in the EMR repository file information with a
new data of update (transaction date) and proceed to add answers/feedback function.
An exit action will return to An exit action will return to the Maintain a Case menu for this case..
5.1.4 Functional Requirements
Requirement ID
Function
REQ-10-01
Display metadata fields required for recording of answers and feedback
and accept reference information or queries associated with this answer.
All new entries have a status of Awaiting Confirmation.
6 Hospital System Simulation
6.1 Patient Index
6.1.1 Description
This function identifies individual fictitious patients in the system. Patients are associated with
cases and their details displayed in the EMR repository display system.
6.1.2 Priority
These features can initially be handled manually though the data requirement and governance
process but are Priority 1 for display of these details in system screens. Note an existing
database of some 700 fictitious patient's already exists.
6.1.3 Stimulus and Response Sequences
This feature is instituted by selection of PMI in the menu.
A save action will:
-store a new or updated Patient file entry in the system. It will not change the links
between the patient and cases (episodes of care)
An exit action will return to the main menu.
6.1.4 Functional Requirements
Requirement ID
Function
REQ-12-01
Enter search criteria and system displays any entries in the PMI file which
match the criteria. (more complex searching not initially required but can
be considered in later stages to simulate real PMI functionality).
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REQ-12-02
Select a patient from the display (or enter new search criteria, or enter new
patient or exit) and the full details for that patient including a list of records
which use this patient is given.
REQ-12-03
Update the patient information, or if a new patient the system should
allocate a UR number .
6.2 Display cases for coding
6.2.1 Description
This function displays the group of records assigned to this student/coder according to the
Course Profile details.
The display indicates whether a case has or has not been coded.
6.2.2 Priority
This feature is required for the initial test of the system (Priority 1).
6.2.3 Stimulus and Response Sequences
This function is instituted by a student selecting Coding from the menu.
A Code the Case record action will:
Display the EMR page for the selected case (if no case is selected - display message select a case first).
Submit All action will submit all cases in the group displayed. Mark each code as complete (for
this student) and select the next cases for this student and display them.
An exit action will return to the main menu.
6.2.4 Functional Requirements
Requirement ID
Function
REQ-13-01
Display all cases currently allocated to this student and show their status. If
a student wants to review their previous coding they can do so through
Review Results - not this functionality.
REQ-13-02
Select a record for coding (this record may have been coded previously or
not)
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7 Clinical Coding Simulation
7.1 View Record
7.1.1 Description
This functionality mimics a Digital or Electronic Health Record functionality. It displays some of
the case metadata (patient details and admission / discharge dates - calculated by the system)
and pages of the record.
7.1.2 Priority
This feature is required for the initial test of the system (Priority 1).
7.1.3 Stimulus and Response Sequences
This function is instituted by a student selecting view record from the Display Cases for Coding
screen.
A Code Case action will:
Open a new screen showing the Coding Screen. This allows the student/coder may
alt/tab between the View Record and Coding screens.
Back to Case List will return to the Display cases for coding screen (4.13)
An exit action will return to the main menu.
7.1.4 Functional Requirements
Requirement ID
Function
REQ-14-01
Display the EMR screen including patient and episode details as well as all
record page titles and allow the user to select a page - the selected page
will be displayed
Note: the system calculates the episode start and end dates, and patient
age from the first date the group of records displayed in the cases for
coding page was opened. i.e. the dates are dynamic and do not need to
be updated to keep the content appearing current.
7.2 Enter Codes
7.2.1 Description
This function displays the episode details and allows the user to enter or view existing codes for
the episode. Codes can be dragged to change their sequence. The description of the code is
displayed for information of the coder.
7.2.2 Priority
This feature is required for the initial test of the system (Priority 1).
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7.2.3 Stimulus and Response Sequences
This function is instituted by a student selecting Code Case from the View Record screen
(4.14).
Submit action will display the DRG metadata for the case if this information is available, if not
available, if it is not available the case will be marked as coded and the answers/feedback is
provided.
Add a question/query action will go to Record Clinical or coding question function.
An exit action will return to the main menu.
7.2.4 Functional Requirements
Requirement ID
Function
REQ-15-01
Display all cases currently allocated to this student and show their status. If
a student wants to review their previous coding they can do so through
Review Results - not this functionality.
REQ-15-02
Select a record for coding (this record may have been coded previously or
not)
7.3 DRG Information
7.3.1 Description
Display of DRG information for the codes entered.
7.3.2 Priority
This feature is not required for the initial test of the system - Stage 2.
7.3.3 Stimulus and Response Sequences
This function is instituted by a student selecting Submit from the Enter Codes screen (4.15).
Next Case will go to View Record for the case next in sequence for coding (i.e. status must be
not coded). will display the DRG metadata for the case if this information is available, if not
available, if it is not available the case will be marked as coded and the answers/feedback is
provided.
Back to modify codes will return to the Enter Codes screen (4.15) and allow the student/coder
to change the codes entered or modify their sequence.
An exit action will return to the Display Cases for Coding.
7.3.4 Functional Requirements
Requirement ID
Function
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REQ-16-01
Interface to DRG grouper and display information received
7.4 Coding Feedback
7.4.1 Description
This function provides feedback to the student/coder, including whether their answer is correct
or not, references, feedback etc.
7.4.2 Priority
This feature is required for the initial test of the system (Priority 1).
7.4.3 Stimulus and Response Sequences
This function is instituted by a student submitting the codes for a case (or entry of next case
from the DRG information function (4.16)
Next Case will go to View Record for the case next in sequence for coding (i.e. status must be
not coded). will display the DRG metadata for the case if this information is available, if not
available, if it is not available the case will be marked as coded and the answers/feedback is
provided.
Question to Tutor/Mentor allows the student/coder to send an email - including the case
information and their answer to their tutor/mentor
An exit action will return to the main menu.
7.4.4 Functional Requirements
Requirement ID
Function
REQ-17-01
Display all cases currently allocated to this student and show their status. If
a student wants to review their previous coding they can do so through
Review Results - not this functionality.
REQ-17-02
Select a record for coding (this record may have been coded previously or
not)
8 Reporting and Discovery
8.1 Student Results Display
8.1.1 Description
This functionality supports reporting of student/coder results.
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8.1.2 Priority
This feature is required for the initial test of the system (Priority 1) though not all features are
essential. The display, print and export of details are sufficient for initial testing, mentor/trainer
notes are an additional requirement.
8.1.3 Stimulus and Response Sequences
This feature is instituted by selection of Student Results in the Student Administration Menu or
from the Course Profile administration Menu. You cannot get to this functionality without a prior
search.
A save action will
- store an update to the Student Results file with a new date of update
Only one student result per Course Profile group (Course Profile ID and optionally Course
Profile Group number) may be current (have a blank end date) at any given point in time.
An exit action will return to the main menu.
8.1.4 Functional Requirements
Requirement ID
Function
REQ-07-01
Display the results for the individual student, or for a Course Profile (which
ever identifier is taken into the process.
REQ-07-02
If the user is a tutor/mentor they may select a specific result and modify
data permitted to be changed, including adding comments. Results may
only be changed if a comment is included.
REQ-07-03
Save , exit or search for another individual or Course Profile (4.5 or 4.4),
print results.
8.2 Cohort Results
8.2.1 Description
This function gives access to the results for a cohort of students.
8.2.2 Priority
This feature is required for the initial test of the system (Priority 1).
8.2.3 Stimulus and Response Sequences
This function is instituted by selection of Results from the main menu
Print - will print the result information and return to the main menu.
An exit action will return to the main menu.
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8.2.4 Functional Requirements
Requirement ID
Function
REQ-18-01
Enter a student ID or Course Profile ID (or display students/Course Profile
for the organisation and allow the user to select the student for display
REQ-18-02
Display each most recent answer for the code group including questions
and modifications or comments made in (4.17)
8.3 Result Summary
8.3.1 Description
A report summarising the results of a student or Course Profile.
8.3.2 Priority
This feature is required for the initial test of the system (Priority 1), but need not be available
when the system first begins.
8.3.3 Stimulus and Response Sequences
Print - will print the results returned
Print Final Result - will print the result for an individual student or group of students without
details of individual case answers.
An exit action will return to the main menu.
8.3.4 Functional Requirements
Requirement ID
Function
REQ-19-01
Enter a student ID or Course Profile ID (or display students/Course Profile
for the organisation and allow the user to select the student/coder or
Course Profile for display
REQ-19-02
Display the total results for the selected student/coder group.
8.4 Other Reports
8.4.1 Description
Reports will be required from the system, but have not been determined as yet.
8.4.2 Priority
This feature is required after the system has been implemented (Priority 2)
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8.4.3 Stimulus and Response Sequences
8.4.4 Functional Requirements
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9 Other Non-functional Requirements
9.1 Performance Requirements
The system must be available at least 22 hours a day for 7 days a week.
Notification of scheduled, or unexpected downtime will be provided to all current students and
organisation contacts.
The speed of the system will be dependent upon the individual's internet speed.
9.2 Safety Requirements
Students/Coders have the right to question any result or answer provided. These queries will
be reviewed by the System Administrator/s and resolved. If unable to be resolved they will be
forwarded to the Governance Committee.
All access to the system will be documented in an Audit trail which is available for review to
organisational users and system administrators.
When a user logs in the following statement must be displayed and must have an affirmative
response:
This system includes simulated health records, the people and cases shown are fictitious.
Despite this it is inappropriate to copy any record or information from the system except to
report a system error.
I agree to abide by these conditions
9.3 Security Requirements
The student and organisational data must be securely and privately maintained. Student/Coder
details shall be available to their organisation (except for individuals, who do not have an
organisation).
9.4 Software Quality Attributes
New records and answers will not be made available to the EMR repository pool until they have
been confirmed by the governance process.
The system will report the error rate of students per case or case group (such as chapter) for
the entire student/coder body (for answers submitted in a defined time frame) or a select group
of student/coders.
When the Answer/Feedback system is modified a test of the system will be undertaken using a
pre-defined set of cases. These are called the Test Cases and represent a selected range of
coding issues and answer situations ensuring that these use cases are tested and acceptable
when a change is implemented.
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9.5 Business Rules
System Administrators may access all functions and data in the system.
Organisation Administrator may access all functions for their tutors/mentors or students.
Tutors/mentors have access to their Course Profile information and results.
Students have access to their registration information, cases for coding or completed, answers,
feedback, queries and results but may not alter answers, feedback, queries or results.
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10 Glossary
Term
Description
EMR
EHR
Electronic Medical Record - in this case a simulated system of
records held in the EMR repository. These records have been deidentified and quality controlled and are associated with metadata
defining the type and level of coding experience provided by the
record.
A single 'page' or form from an individual EMR
A single ICD-10-AM code
A student, coder or administrator of the system
An episode of care to be coded . Each case has an Admission and
Discharge Date and additional information about the inpatient event.
The computer system used to collect and process codes
ICD-10-AM - though any code system could be used. Each EMR
may have answers stored for different editions of a single
classification system or for multiple classification systems or
editions.
A hospital, education provider, professional body or other similar
group of people.
Page
Code
User
Case / Episode
Coding System
Classification System
Organization
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