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HIM review
Health Information Management Review
| Question | Answer |
|---|---|
| - | minus; negative |
| " | inch |
| # | number; following a number; pound |
| % | percent |
| @ | at |
| ' | foot |
| + | positive; plus |
| = | equals |
| + - | plus or minus; either positive or negative; indefinite |
| . - ., / | divided by |
| o | degree |
| A | auscultation and percussion |
| aa | of each |
| ADLs | activities of daily living |
| AHP | administrative health professional |
| AP | anteroposterior |
| BP, B/P | blood pressure |
| Bx, bx | biopsy |
| c/o | complains of |
| CC | chief complaint |
| CHIM | Canadian Health Information Manager |
| CHIMA | Canadian Health Information Management AssociationCPO |
| CPX | complete physical examination |
| D.O., DO | Doctor of Osteopathy |
| D.P.M. | Doctor of podiatric medicine |
| dc, DC, D/C | discharge, discontinue |
| Dx | diagnosis |
| ED | emergency department |
| EMR | electronic medical record |
| FH | family history |
| FI | functional inquiry |
| Fx | fracture |
| G | gravida (pregnant) |
| HPI | history of present illness |
| Hx | history |
| LLQ | left lower quadrant |
| LMP | last menstrual period |
| lt | left |
| LUQ | left upper quadrant |
| MRP | most responsible physician |
| MS | mental status |
| NSAIDs | nonsteroidal anti-inflammatory drugs |
| O.D. | Doctor of optemetry |
| OP | outpatient; operative procedure |
| ORTH, ortho | orthopedics |
| PA | posteroanterior |
| Pap | papanicolaou (test) |
| para 1, 2, 3, and so on | unipara, bipara,tripara, and so on (# of viable births) |
| PCP | primary care physician |
| PE | physical examination |
| PH | medical history |
| PHIPA | personal health information protection act |
| PIPEDA | personal information protection and electronic documents act |
| PMH | past medical history |
| PMP | previous menstrual period |
| post | posterior |
| R/O | rule out |
| RLQ | right lower quadrant |
| rt | right |
| RUQ | right upper quandrant |
| Rx | prescription |
| SOAP | subjective objective assessment plan |
| SOB | shortness of breath |
| sono | sonogram |
| stat., STAT | immediately |
| Sx | symptom |
| ther | therapy |
| TPR | temperature, pulse, and respiration |
| Tx | treatment |
| U&L, U/L | upper and lower |
| UA | urinalysis |
| URI | upper respiratory infection |
| WD | well-developed |
| WN | well-nourished |
| WNL | within normal limits |
| x | multipled by; magnification |
| A clear link must be established between the information that is collected and the reason for doing so | limiting collection of personal information |
| A database of all clents registered | master patient index (MPI) |
| A federally funded organization with a mandate to facilitate the national implementation of electronic health records | the 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 | 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 | fob |
| A system for keeping track of paper health records taken from their normal location | outguiding system/chargeout system |
| A total medical office system, including both hardware and software, with the capability of replacing all components of a paper chart electronically | electronic medical records systems |
| Allows parts of the record to reside outside 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 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 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 storage |
| Distribution of and access to information is strictly controlled | provision |
| Each client is assigned a unique identifier | identification system |
| 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 reports |
| 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 results |
| May be formally prepared or noted on the progress notes | phsical assessment |
| Normally used for records that are pre-numbered | consecutive |
Created by:
shann77
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