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Purple Module
Health Infornmation Mgmt Review
| Term | Definition |
|---|---|
| Limited collection of personal information (PI) | a clear link 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 |
| Cdn Health Infoway | A federally funded organization with mandate to facilitate the national implementation of electric health records |
| Health Information Management (HIM) | a field in its own right |
| E Health | a general term used to describe electronic health information |
| Electronic Medical Record (EMR) | a legal health record in digital format. Contains clients health information collected by providers in one location. Is a subset of electronic health record (EHR) |
| Health Information Custodian | a person(s) or organization who has the responsibility for safekeeping and controlling personal health information |
| FOB | a small security device that can be added to a computer for access purposes, displays randomly generated access code that changes every few seconds |
| Outguiding System /Change Out 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 HW and SW, capable of replacing all components of a paper charting system. |
| decentralized | allow parts of the record to reside outside HIS |
| Electronic Health Records (EHR) | a accumulation of essential information from an individuals EMR that is accessed electronically at different points of service for purposes of client care |
| Health Record | any document relating to a health-care client. Can be single document or collection of documents |
| Health Information | any information pertaining to someone's physical or mental health condition, or infirmity whether given orally or recorded in any manner. |
| Operative Reports | any surgical procedures 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 specified to doctor to keep all information confidential |
| colour coding | combination of alphabetical or numeric filing system with coloured tabs |
| consent form | consent must be obtained in order to collect information |
| centralized storage | designated one location in which to house all records |
| provision | distribution of an access to information is strictly controlled |
| Identification Systems | each client is assigned a unique identifier |
| Challenging Compliance | each organization must have a process in place to handle complaints which complies with gov't legislation |
| eChart | electronic chart |
| miscellaneous (charting) | growth chart, antenatal charts, diabetic flow sheets etc. |
| personal information defined | includes information that maybe considered factual or subjective |
| openess | information about policies relating to the management of persons information must be readily available to the client |
| accuracy | information should be accurate and complete in terms of how it is recorded to facilitate its proper use (PIPEDA) |
| lab sheets | keep together with most current on top |
| physical assessment | maybe formally prepared or noted on the progress report |
| consecutive (numeric) | filing systems 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 most straight forward flying system; direct access system |
| maintenance | organizing records through some kind of filing system |
| pChart | paper chart |
| accountability | PIO who is ultimately responsible of the compliance of the organization with standards spelled out in the act (PIPEDA) |
| cumulative patient profile (CPP) | provides a cumulative view of history and current health status |
| history (interview) sheet | questionnaire that the client completes on first visit |
| numeric | filing system require index; indirect access system |
| purge | review and reorganize to remove outdated information that is no longer actively needed in a client's chart |
| terminal digit | filing system with segments of numbers divided into component parts |
| list of allergies | should be noted in red and listed in a prominent place on history sheet |
| creation | initial retrieval of information |
| safe guard | organization must take appropriate and practical measures to protect the information from unauthorized access, use or tampering |
| archive | remove a file from active status and store it in a secondary location |
| unlawful access | violates the law and moral and ethical principles (PIPEDA) |
| individual access | with written request to the PIO, clients shall be given access to their personal information (PIPEDA) |
| limiting use, disclosure, and retention | 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 servers its intended purpose. Must be appropriately stored and destroyed. (PIPEDA) |
| identifying process | you must inform the clients of the purpose for the collection of their information either before or at the time of the collection (PIPEDA) |
Created by:
amatt
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