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HIM Review
Reverse Definitions
| 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 | 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 |
| Electrical Medical Record | A legal health record in digital format. Contains 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 chargeout system | as system for keeping track of paper health records taken from their normal location |
| electronic medical records systems | a total medical office systems, 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 | 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 collective 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 |
| color 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 strickly controlled |
| ID systems | each client is assigned a unique identifier |
| challenging compliance | each organization must have a process in a 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 legislative |
| eChart | electronic chart |
| miscellaneous | growth charts, antenatal records, diabetic flow sheets |
| personal information | includes information that may be considered factual or subjective |
| openness | 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 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 |
| accountablity | 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 | questionnaire 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 |
| archive | to remove a file from active status and store it in a secondary location or an 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 |
| limited 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 its 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 |
Created by:
JessP
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