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Purple Module
H.I.M. Review
| Question | Answer |
|---|---|
| A clear link must be established between the information that is collected and the reason for doing so | limiting collection of personal information (PI) |
| A database of all client's registered | master patient index (MPI) |
| A federally funded organization with a mandate to facilitate the national implemantation of electronic health records | 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 (EHR) | 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 that can be added to a computer for access purposes. It displays a randomly generated acecss code that changes every few seconds | fob |
| A system for keeping track of paper health records taken from their normal location | outguiding system/ charge-out system |
| A total medical office system, including both hardware and software, with the capability of replacing all components of a paper chart ( health record) electronically | electronic medical records system |
| Allows parts of the record to reside outside the 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 documentation relating to a ehalth-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 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 |
| Distribution of and access to information is strickly controlled | provision |
| Each client is assigned a unique identifier | ID systems |
| 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 |
| 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 sheets |
| May be formally prepared or noted on the progress notes | physical assessment |
| Normally used for records that are pre-numbered | consecutive |
| Occurs each time a client has an encounter with a health-care provider | encounter record |
| Oldest and most straightforward; direct access system | alphabetical |
| Organizing records through some kind of filing system | maintenance |
| Paper chart | pChart |
| PIO who is ultimately responsible for the compliance of the organization with the standards spelled out in the act | accountability |
| Provides a cumulative view of history and current health status | cumulative patient profile (CPP) |
| Questionnaire that the client is asked to fill out on first visit | history (interview) sheet |
| Requires an index; indirect access system | numeric |
| Review and reorganize to remove outdated information that is no longer actively needed to provide care to the client | purge |
| Segments a number into component parts | terminal digit |
| Should be noted in red and listed in a prominent place | list of allergies |
| The initial retrieval of information | creation |
| The organization must take appropriate and practical measures to protect the information from unauthorized access, use or tampering | safeguards |
| To remove a file from active status and store it in a secondary location or on a secondary medium | archive |
| Violates the law and moral and ethical principles | unlawful access |
| With written request to the PIO, clients shall be given access to their personal information | individual access |
| 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 | limiting use, disclosure, and retention |
| You must inform the clients of the purpose for the collection of their information either before or at the time of the collection | identifying purposes |
| A | auscultation and percussion |
| ADLs | activities of daily living |
| BP, B/P | blood pressure |
| Bx | biopsy |
| c/o | complains of, complaints |
| 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 |
| OP | outpatient; operative procedure |
| ORTH,orth | orthopedics |
| PCP | primary care physician |
| PE | physical examination |
| PMH | past medical history |
| R/O, r/o | rule out |
| Rx | prescription |
| SOAP | subjective, objective, assessment, plan |
| SOB | shortness of breath |
| STAT, stat | immediately |
| Sx | symptoms |
| WD | well-developed |
| WN | well-nourished |
| WNL | within normal limits |
Created by:
DawnLangridge
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