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HIM review

Health Information Management Review

- minus; negative
" inch
# number; following a number; pound
% percent
@ at
' foot
+ positive; plus
= equals
+ - plus or minus; either positive or negative; indefinite
. - ., / divided by
o degree
A auscultation and percussion
aa of each
ADLs activities of daily living
AHP administrative health professional
AP anteroposterior
BP, B/P blood pressure
Bx, bx biopsy
c/o complains of
CC chief complaint
CHIM Canadian Health Information Manager
CHIMA Canadian Health Information Management AssociationCPO
CPX complete physical examination
D.O., DO Doctor of Osteopathy
D.P.M. Doctor of podiatric medicine
dc, DC, D/C discharge, discontinue
Dx diagnosis
ED emergency department
EMR electronic medical record
FH family history
FI functional inquiry
Fx fracture
G gravida (pregnant)
HPI history of present illness
Hx history
LLQ left lower quadrant
LMP last menstrual period
lt left
LUQ left upper quadrant
MRP most responsible physician
MS mental status
NSAIDs nonsteroidal anti-inflammatory drugs
O.D. Doctor of optemetry
OP outpatient; operative procedure
ORTH, ortho orthopedics
PA posteroanterior
Pap papanicolaou (test)
para 1, 2, 3, and so on unipara, bipara,tripara, and so on (# of viable births)
PCP primary care physician
PE physical examination
PH medical history
PHIPA personal health information protection act
PIPEDA personal information protection and electronic documents act
PMH past medical history
PMP previous menstrual period
post posterior
R/O rule out
RLQ right lower quadrant
rt right
RUQ right upper quandrant
Rx prescription
SOAP subjective objective assessment plan
SOB shortness of breath
sono sonogram
stat., STAT immediately
Sx symptom
ther therapy
TPR temperature, pulse, and respiration
Tx treatment
U&L, U/L upper and lower
UA urinalysis
URI upper respiratory infection
WD well-developed
WN well-nourished
WNL within normal limits
x multipled by; magnification
A clear link must be established between the information that is collected and the reason for doing so limiting collection of personal information
A database of all clents registered master patient index (MPI)
A federally funded organization with a mandate to facilitate the national implementation of electronic health records the Canada health infoway
A field in its own right health information management (HIM)
A general term used to describe electronic health information eHealth
A legal health record in digital format. It contains the client's health information collected by one or a group of providers in one location. It is a subset of the electronic health record electronic medical record (EMR)
A person, persons, or organization who has the responsibility for safekeeping and controlling personal health information in connection with the powers and duties performed. health information custodian
A small security device fob
A system for keeping track of paper health records taken from their normal location outguiding system/chargeout system
A total medical office system, including both hardware and software, with the capability of replacing all components of a paper chart electronically electronic medical records systems
Allows parts of the record to reside outside HIS decentralized
An accumulation of essential information from an individual's electronic medical records that is accessed electronically at different points of service for purposes of client care electronic health record (EHR)
Any document relating to a health care client. The term record is used for a single document, such as a doctor's note on an assessment or a lab report; it also refers to a collection of documents, such as a client chart health record
Any information pertaining to someone's physical or mental health, condition, or infirmity, whether given orally or recorded in any manner, that is created or received directly or indirectly by a health professional or health organization health information
Any surgical procedure will generate a report operative reports
As long as a client is alive and has the potential to seek treatment, a health record remains active disposition
Client has specifically asked the doctor to keep confidential lock boxes
Combination of alphabetical or numeric with colour colour coding
Consent must be obtained in order to collect the information consent form
Designate one location in which to house all records centralized storage
Distribution of and access to information is strictly controlled provision
Each client is assigned a unique identifier identification system
Each organization must have a process in place to handle complaints with respect to the way personal information is collected, used, or disclosed, or the manner in which the organization complies with the legislation challenging compliance
Electronic chart eChart
Growth charts,antenatal records,diabetic flow sheets etc miscellaneous reports
Includes information that may be considered factual or subjective personal information
Information about policies relating to the management of person information must be readily available to the clients openness
Information should be accurate and complete in terms of how it is recorded to facilitate its proper use accuracy
Keep together with most current on top lab results
May be formally prepared or noted on the progress notes phsical assessment
Normally used for records that are pre-numbered consecutive
Created by: shann77