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Purple Mod
Health Information Management Review
Term | Definition |
---|---|
Limiting Collection of 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 |
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 medical record (EMR) | 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 |
outguiding system/or charge-out system | a system for keeping track of paper health records taken from their normal location |
electronic medical records system (EMR 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 documentation 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 lap report; it also refers to a collection of documents, such as a client's chart. |
health information | any information pertaining to someones 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 report | 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 |
centralized | designate one location in which to house all records |
provision | distribution of and access to information is strictly controlled |
ID system | 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 | growth charts, antenatal records, diabetic flow sheets, etc |
personal information | includes information that may be considered factual or subjective |
openness | information about policies relating to the management of personal information must be readily available to clients |
accuracy | information should be accurate and complete in terms of how it is recorded to facilitate its proper use |
lab sheets | 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 (CPP) | provides a cumulative view of history and current health status |
history (interview) sheet | questionnaire that the client is asked to fill out on first visit |
numeric | requires an index; indirect access system |
purge | (of file) 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 |
archive | 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 & retention | 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 |
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 |