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Purple Module

H.I.M. Review

A clear link must be established between the information that is collected and the reason for doing so limiting collection of personal information (PI)
A database of all client's registered master patient index (MPI)
A federally funded organization with a mandate to facilitate the national implemantation of electronic health records 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 (EHR) 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 that can be added to a computer for access purposes. It displays a randomly generated acecss code that changes every few seconds fob
A system for keeping track of paper health records taken from their normal location outguiding system/ charge-out system
A total medical office system, including both hardware and software, with the capability of replacing all components of a paper chart ( health record) electronically electronic medical records system
Allows parts of the record to reside outside the 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 documentation relating to a ehalth-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's 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
Distribution of and access to information is strickly controlled provision
Each client is assigned a unique identifier ID systems
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
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 sheets
May be formally prepared or noted on the progress notes physical assessment
Normally used for records that are pre-numbered consecutive
Occurs each time a client has an encounter with a health-care provider encounter record
Oldest and most straightforward; direct access system alphabetical
Organizing records through some kind of filing system maintenance
Paper chart pChart
PIO who is ultimately responsible for the compliance of the organization with the standards spelled out in the act accountability
Provides a cumulative view of history and current health status cumulative patient profile (CPP)
Questionnaire that the client is asked to fill out on first visit history (interview) sheet
Requires an index; indirect access system numeric
Review and reorganize to remove outdated information that is no longer actively needed to provide care to the client purge
Segments a number into component parts terminal digit
Should be noted in red and listed in a prominent place list of allergies
The initial retrieval of information creation
The organization must take appropriate and practical measures to protect the information from unauthorized access, use or tampering safeguards
To remove a file from active status and store it in a secondary location or on a secondary medium archive
Violates the law and moral and ethical principles unlawful access
With written request to the PIO, clients shall be given access to their personal information individual access
You cannot use or disclose any information for purposes other than those for which it was collected; information must be kept only as long as it serves its intended purpose; information must be appropriately stored and destroyed limiting use, disclosure, and retention
You must inform the clients of the purpose for the collection of their information either before or at the time of the collection identifying purposes
A auscultation and percussion
ADLs activities of daily living
BP, B/P blood pressure
Bx biopsy
c/o complains of, complaints
CC chief complaint
CPX complete physical examination
Dx diagnosis
EMR electronic medical record
FH family history
Fx fracture
HPI history of present illness
Hx history
LMP last menstrual period
MRP most responsible physician
MS mental status
OP outpatient; operative procedure
ORTH,orth orthopedics
PCP primary care physician
PE physical examination
PMH past medical history
R/O, r/o rule out
Rx prescription
SOAP subjective, objective, assessment, plan
SOB shortness of breath
STAT, stat immediately
Sx symptoms
WD well-developed
WN well-nourished
WNL within normal limits
Created by: DawnLangridge