Health Information Management Review
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| Limiting Collection of PI | a clear link must be established between the information that is collected and the reason for doing so
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| Master patient index (MPI) | a database of all clients registered
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| Canada Health Infoway | a federally funded organization with a mandate to facilitate the national implementation of electronic health records
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| health information management (HIM) | a field in its own right.
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| eHealth | a general term used to describe electronic health information
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| 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)
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| 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.
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| 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
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| outguiding system/or charge-out system | a system for keeping track of paper health records taken from their normal location
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| electronic medical records system (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.
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| decentralized | allows parts of the record to reside outside HIS
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| 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.
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| health record | any documentation 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 lap report; it also refers to a collection of documents, such as a client's chart.
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| health information | any information pertaining to someones 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
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| operative report | any surgical procedure will generate a report
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| disposition | as long as a client is alive and has the potential to seek treatment, a health record remains active.
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| lock boxes | client has specifically asked the doctor to keep confidential
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| colour coding | combination of alphabetical or numeric with colour
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| consent form | consent must be obtained in order to collect the information
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| centralized | designate one location in which to house all records
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| provision | distribution of and access to information is strictly controlled
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| ID system | each client is assigned a unique identifier
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| 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.
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| eChart | electronic chart
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| miscellaneous reports | growth charts, antenatal records, diabetic flow sheets, etc
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| personal information | includes information that may be considered factual or subjective
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| openness | information about policies relating to the management of personal information must be readily available to clients
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| accuracy | information should be accurate and complete in terms of how it is recorded to facilitate its proper use
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| lab sheets | keep together with most current on top
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| physical assessment | may be formally prepared or noted on the progress notes
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| consecutive | normally used for records that are pre-numbered
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| encounter record | occurs each time a client has an encounter with a health-care provider
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| alphabetical | oldest and most straightforward; direct access system
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| maintenance | organizing records through some kind of filing system
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| pChart | paper chart
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| accountability | PIO who is ultimately responsible for the compliance of the organization with the standards spelled out in the act
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| cumulative patient profile (CPP) | provides a cumulative view of history and current health status
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| history (interview) sheet | questionnaire that the client is asked to fill out on first visit
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| numeric | requires an index; indirect access system
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| purge | (of file) review and reorganize to remove outdated information that is no longer actively needed to provide care to the client
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| terminal digit | segments a number into component parts
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| list of allergies | should be noted in red and listed in a prominent place
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| creation | the initial retrieval of information
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| safeguards | the organization must take appropriate and practical measures to protect the information from unauthorized access, use or tampering
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| archive | to remove a file from active status and store it in a secondary location or on a secondary medium
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| unlawful access | violates the law and moral and ethical principles
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| individual access | with written request to the PIO, clients shall be given access to their personal information
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| limiting use, disclosure & 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
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| 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
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