Imagine that you are the HIM director for a pediatric medical practice. The practitioners have asked you to consider a well-child visit for a 12-month-old child and to build a data dictionary to include several data items. During the well-child visit, the practitioners want to document no fewer than the following data elements:
The child’s:
Date of birth
Height
Weight
Temperature
Sex
Growth percentile
Parental reports of (using simple yes/no fields) any issues with the child’s:
Hearing
Vision
Speaking
Standing/mobility
Parental responses (using simple yes/no fields) to the following:
Does child have teeth brushed daily?
Do any adults in the child’s household smoke?
To proceed with the build of your data dictionary, follow the table format shown in the “Maternity Care Data Dictionary” example in this module. Be sure to establish useful attribute names, data types, necessary data lengths, and descriptions.
Note: An actual, final visit documentation system ultimately would contain free-form notes from the provider, but your data dictionary does not need to provide for such fields at this time.
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