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h.i.m review
review for HiM
| Question | Answer |
|---|---|
| limiting collection of P.I | 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 |
| electronic medical record | A legal health record in digital format. it contains the clients health information collected by one or a group of providers in one location. It is a subset of electronic health records (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 changeout system | A system fort keeping track of paper health records taken from their normal location |
| electronic medical records 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 | An accumulation of essential information from an individuals electronic medical records that is accessed electronically at dfifferent 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 doctors 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 someones physical or mental health, condition, o infirmity, whether given orally or recorded in any manner, that is created or received directly or indirectly by a health professional or health orginization |
| operative report | Any surgical 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 |
| I.D 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 |
| 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 | maybe 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 straight forward 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 | provides a cummulative view of history and current health status |
| history (interview) sheet | questionaire that the client is asked to fill out on first visit |
| numeric | requires an index indirect access system |
| purge | review and re-organize 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 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 could not use or disclose any information for purposes other then 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 |
| A&P | auscultation 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 |
| OP | out patient; operative procedure |
| ORTH, ortho | orthopedics |
| PCP | primary care physician |
| PE | physical examination |
| PMH | past medical history |
| R/O | rule out |
| Rx | prescription |
| SOAP | subject, objective, assessment, plan |
| SOB | shortness of breath |
| STAT | immediately |
| Sx | symptom |
| WD | well-developed |
| WN | well-nourished |
| WNL | within normal limits |
Created by:
AshleyMcM
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