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Purple Module

Health Information Management

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
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
Created by: Barbara Ross



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