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h.i.m review

review for HiM

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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