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HIM Review
Purple Module - Health Information Management Review
| Term | Definition |
|---|---|
| limiting collection of personal information | 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 |
| The 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 it's 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 had 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 | A system for keeping track of paper health records taken from their normal location |
| electronic medical records systems (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 of 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. |
| centralized | Designate 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 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 |
| miscellanious | 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 the most current on top. |
| physical assessment | May be formally prepared or noted in the progress notes. |
| consecutive | Normally used for records that are pre-numbered |
| encounter record | Occurs each time the 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 | 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 location |
| creation | The initial retrieval of information |
| safeguards | The organization must take appropriate and practical measured 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, and 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 collection. |
| A&P | ascultation and 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 menstrual period |
| MRP | most responsible physician |
| MS | mental status; multiple sclerosis |
| OP | out patient; operative procedure |
| ORTH, ortho | orthopedics |
| PCP | primary care physician |
| PE | physical examination; pressure-equalizing |
| PMH | past medical history |
| R/O | rule out |
| Rx | prescription |
| SOAP | subjective, objective, assessment, plan |
| SOB | shortness of breath |
| STAT | immediately |
| Sx | symptom |
| WD | well-developed |
| WN | well-nourished |
| WNL | within normal limits |
Created by:
Cellyvision
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