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HIM review
PURPLE MOD
Question | Answer |
---|---|
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 | a field in its own right |
eHealth | a general term used to describe electronic health information |
electronic medical records | a legal health record in digital format. It contains the client's health information collected by one of a group of providers in one location. It is a subset of the 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 perferomed |
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 change out system | a system for keeping track of paper health records taken from their normal location |
electronic medical records system (EMR 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 |
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 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 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 | 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 the 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 |
cummulative 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 |