Question | Answer |
limiting collection of personal information (PI) | A clear ling 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. |
Canada Health Infoway | A federally funded organization with a mandate to facilitate the national implementation of electronic health records. |
health information management (HIM) | A field in its own right. |
ehealth | A general term used to describe electronic health information. |
electronic health record (EHR) | 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 has 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. |
outgoing system/chargeout 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 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 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. |
central storage | Designate one location in which to house all records. |
provision | Distribution of and access to information is strictly controlled. |
(ID) 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 |
miscellaneous reports/charting | Growth charts, antenatal records, diabetic flow sheets, etc. |
personal identification defined | Includes information that may be considered factual or subjective. |
openess | Information about policies relating to the management of person 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 results | Keep together with most current on top. |
physical assessment | May be formally prepared or noted on the progress notes. |
consecutive | 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 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 | Provides a cumulative view of history and current health status. |
history sheet | Questionnarie 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 place. |
creation | The initial retrieval of information. |
safeguards | The organization must take appropriate and practical measures to protect the information from unauthorized access, use or tampering. |
achive | 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 then 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 the collection. |
A & P | auscultation & 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 menstral period |
MRP | most responsible physician |
MS | mental statis |
OP | outpatient, operative proceedure |
ORTH, ortho | orthopedics |
PCP | primary care physician |
PE | physical examination |
PMH | post medical history |
R/O | rule out |
RX | prescription |
SOAP | subjective, objective, assessment and plan. |
STAT | immediately |
SOB | shortness of breath |
Sx | symptom |
WD | well-developed |
WN | well-nourished |
WNL | within normal limits |
- | negative, minus |
" | inch |
# | number, pound |
% | percent |
@ | at |
' | apostrophy, feet |
+ | plus, positive |
= | equals |
+- | plus or minus, indefinite |
/ | divided by |
| degrees |
aa | of each |
AHP | administrative health professional |
AP | anteroposterior |
CHIM | Canadian Health Information Manager |
CHIMA | Canadian Health Information Management Association |
D.O., DO | Doctor of Osteopathy |
D.P.M. | Doctor of Podiatric Medicine |
dc, DC, D/C | discharge, discontinue |
ED | Emergency Department |
FI | functional inquiry |
G | gravida (pregnant) |
LLQ | lower left quadrant |
lt | left |
LUQ | left upper quadrant |
NSAIDS | nonsteriod anti-inflammatory drugs |
O.D. | Doctor of Optometry |
PA | posteroanterior |
Pap | Papanicolaou (test) |
para 1, 2, 3, and so on | unipara, bipara, tripara (number of viable births) |
PHIPA | Personal Health Information Protection Act |
PIPEDA | Personal Information Protection and Electronic Documents Act |
post | posterior |
sono | sonogram |
ther | therapy |
TPR | temperature, pulse and respirations |
U & L, U/L | upper and lower |
UA | urinalysis |
URI | upper respiratory infection |
x | multiplied by, magnification |
| change; heat |
| to, in the direction of |
| increase(d), up |
| decrease(d), down |
| male |
| female |