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Purple Module
Health Information Management
| 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 |
Created by:
Barbara Ross
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