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Purple Module

Health Infornmation Mgmt Review

Limited collection of personal information (PI) a clear link must be established between the information that is collected and the reason for doing so.
Master Patient Index (MPI) a database of all clients registered
Cdn Health Infoway A federally funded organization with mandate to facilitate the national implementation of electric health records
Health Information Management (HIM) a field in its own right
E Health a general term used to describe electronic health information
Electronic Medical Record (EMR) a legal health record in digital format. Contains clients health information collected by providers in one location. Is a subset of electronic health record (EHR)
Health Information Custodian a person(s) or organization who has the responsibility for safekeeping and controlling personal health information
FOB a small security device that can be added to a computer for access purposes, displays randomly generated access code that changes every few seconds
Outguiding System /Change Out System a system for keeping track of paper health records taken from their normal location
Electronic Medical Records Systems a total medical office system including both HW and SW, capable of replacing all components of a paper charting system.
decentralized allow parts of the record to reside outside HIS
Electronic Health Records (EHR) a accumulation of essential information from an individuals EMR that is accessed electronically at different points of service for purposes of client care
Health Record any document relating to a health-care client. Can be single document or collection of documents
Health Information any information pertaining to someone's physical or mental health condition, or infirmity whether given orally or recorded in any manner.
Operative Reports any surgical procedures will generate a report
disposition as long as a client is alive and has the potential to seek treatment, a health record remains active
lock boxes client has specified to doctor to keep all information confidential
colour coding combination of alphabetical or numeric filing system with coloured tabs
consent form consent must be obtained in order to collect information
centralized storage designated one location in which to house all records
provision distribution of an access to information is strictly controlled
Identification Systems each client is assigned a unique identifier
Challenging Compliance each organization must have a process in place to handle complaints which complies with gov't legislation
eChart electronic chart
miscellaneous (charting) growth chart, antenatal charts, diabetic flow sheets etc.
personal information defined includes information that maybe considered factual or subjective
openess information about policies relating to the management of persons information must be readily available to the client
accuracy information should be accurate and complete in terms of how it is recorded to facilitate its proper use (PIPEDA)
lab sheets keep together with most current on top
physical assessment maybe formally prepared or noted on the progress report
consecutive (numeric) filing systems normally used for records that are pre-numbered
Encounter Record occurs each time a client has an encounter with a health-care provider
alphabetical oldest most straight forward flying system; direct access system
maintenance organizing records through some kind of filing system
pChart paper chart
accountability PIO who is ultimately responsible of the compliance of the organization with standards spelled out in the act (PIPEDA)
cumulative patient profile (CPP) provides a cumulative view of history and current health status
history (interview) sheet questionnaire that the client completes on first visit
numeric filing system require index; indirect access system
purge review and reorganize to remove outdated information that is no longer actively needed in a client's chart
terminal digit filing system with segments of numbers divided into component parts
list of allergies should be noted in red and listed in a prominent place on history sheet
creation initial retrieval of information
safe guard organization must take appropriate and practical measures to protect the information from unauthorized access, use or tampering
archive remove a file from active status and store it in a secondary location
unlawful access violates the law and moral and ethical principles (PIPEDA)
individual access with written request to the PIO, clients shall be given access to their personal information (PIPEDA)
limiting use, disclosure, and retention 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 servers its intended purpose. Must be appropriately stored and destroyed. (PIPEDA)
identifying process you must inform the clients of the purpose for the collection of their information either before or at the time of the collection (PIPEDA)
Created by: amatt