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HIM Review

Purple Module - Health Information Management Review

limiting collection of personal information 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
The Canada Health Infoway A federally funded organization with a mandate to facilitate the national implementation of electronic health records
health information management A field in it's own right
eHealth A general term used to describe electronic health information
electronic medical record (EMR) 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).
health information custodian A person, persons, or organization who had the responsibility for safekeeping and controlling personal health information in connection with the powers and duties performed
fob A small security device that can be added to a computer for access purposes. It displays a randomly generated access code that changes every few seconds.
outguiding system A system for keeping track of paper health records taken from their normal location
electronic medical records systems (EMR systems) A total medical office system, including both hardware and software, with the capability of replacing all components of a paper chart (health record) electronically.
decentralized Allows parts of the record to reside outside of HIS
electronic health record (EHR) 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.
health record 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's chart.
health information 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.
operative reports Any surgical procedure 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 specifically asked the doctor to keep confidential.
colour coding Combination of alphabetical or numeric with colour.
consent form Consent must be obtained in order to collect the information.
centralized Designate 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 with respect to the way personal information is collected, used, or disclosed, or the manner in which the organization complies with the legislation.
eChart Electronic chart
miscellanious Growth charts, antenatal records, diabetic flow sheets, etc.
personal information Includes information that may be considered factual or subjective
openness Information about policies relating to the management of personal information must be readily available to the clients
accuracy Information should be accurate and complete in terms of how it is recorded to facilitate its proper use.
lab sheets Keep together with the most current on top.
physical assessment May be formally prepared or noted in the progress notes.
consecutive Normally used for records that are pre-numbered
encounter record Occurs each time the client has an encounter with a health-care provider.
alphabetical Oldest and most straightforward; direct access system
maintenance Organizing records through some kind of filing system
pChart Paper chart.
accountability PIO who is ultimately responsible for the compliance of the organization with the standards spelled out in the act.
cumulative patient profile (CPP) Provides a cumulative view of history and current health status
history (interview) sheet Questionnaire that the client is asked to fill out on first visit
numeric Requires an index; indirect access system
purge Review and reorganize to remove outdated information that is no longer actively needed to provide care to the client.
terminal digit Segments a number into component parts.
list of allergies Should be noted in red and listed in a prominent location
creation The initial retrieval of information
safeguards The organization must take appropriate and practical measured to protect the information from unauthorized access, use or tampering.
archive To remove a file from active status and store it in a secondary location or on a secondary medium
unlawful access Violates the law and moral and ethical principles.
individual access With written request to the PIO, clients shall be given access to their personal information.
limiting use, disclosure, and retention 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.
identifying purposes You must inform the clients of the purpose for the collection of their information either before or at the time of collection.
A&P ascultation and percussion
ADLs activities of daily living
BP, B/P blood pressure
Bx biopsy
c/o complains of
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; multiple sclerosis
OP out patient; operative procedure
ORTH, ortho orthopedics
PCP primary care physician
PE physical examination; pressure-equalizing
PMH past medical history
R/O rule out
Rx prescription
SOAP subjective, objective, assessment, plan
SOB shortness of breath
STAT immediately
Sx symptom
WD well-developed
WN well-nourished
WNL within normal limits
Created by: Cellyvision