Health Information Management Review
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on it to display the answer.
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| - | minus; negative
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| " | inch
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| # | number; following a number; pound
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| % | percent
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| @ | at
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| ' | foot
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| + | positive; plus
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| = | equals
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| + - | plus or minus; either positive or negative; indefinite
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| . - ., / | divided by
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| o | degree
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| A | auscultation and percussion
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| aa | of each
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| ADLs | activities of daily living
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| AHP | administrative health professional
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| AP | anteroposterior
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| BP, B/P | blood pressure
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| Bx, bx | biopsy
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| c/o | complains of
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| CC | chief complaint
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| CHIM | Canadian Health Information Manager
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| CHIMA | Canadian Health Information Management AssociationCPO
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| CPX | complete physical examination
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| D.O., DO | Doctor of Osteopathy
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| D.P.M. | Doctor of podiatric medicine
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| dc, DC, D/C | discharge, discontinue
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| Dx | diagnosis
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| ED | emergency department
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| EMR | electronic medical record
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| FH | family history
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| FI | functional inquiry
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| Fx | fracture
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| G | gravida (pregnant)
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| HPI | history of present illness
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| Hx | history
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| LLQ | left lower quadrant
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| LMP | last menstrual period
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| lt | left
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| LUQ | left upper quadrant
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| MRP | most responsible physician
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| MS | mental status
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| NSAIDs | nonsteroidal anti-inflammatory drugs
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| O.D. | Doctor of optemetry
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| OP | outpatient; operative procedure
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| ORTH, ortho | orthopedics
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| PA | posteroanterior
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| Pap | papanicolaou (test)
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| para 1, 2, 3, and so on | unipara, bipara,tripara, and so on (# of viable births)
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| PCP | primary care physician
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| PE | physical examination
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| PH | medical history
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| PHIPA | personal health information protection act
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| PIPEDA | personal information protection and electronic documents act
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| PMH | past medical history
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| PMP | previous menstrual period
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| post | posterior
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| R/O | rule out
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| RLQ | right lower quadrant
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| rt | right
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| RUQ | right upper quandrant
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| Rx | prescription
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| SOAP | subjective objective assessment plan
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| SOB | shortness of breath
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| sono | sonogram
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| stat., STAT | immediately
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| Sx | symptom
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| ther | therapy
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| TPR | temperature, pulse, and respiration
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| Tx | treatment
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| U&L, U/L | upper and lower
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| UA | urinalysis
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| URI | upper respiratory infection
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| WD | well-developed
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| WN | well-nourished
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| WNL | within normal limits
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| x | multipled by; magnification
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| A clear link must be established between the information that is collected and the reason for doing so | limiting collection of personal information
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| A database of all clents registered | master patient index (MPI)
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| A federally funded organization with a mandate to facilitate the national implementation of electronic health records | the Canada health infoway
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| A field in its own right | health information management (HIM)
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| A general term used to describe electronic health information | eHealth
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| 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 | electronic medical record (EMR)
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| A person, persons, or organization who has the responsibility for safekeeping and controlling personal health information in connection with the powers and duties performed. | health information custodian
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| A small security device | fob
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| A system for keeping track of paper health records taken from their normal location | outguiding system/chargeout system
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| A total medical office system, including both hardware and software, with the capability of replacing all components of a paper chart electronically | electronic medical records systems
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| Allows parts of the record to reside outside HIS | decentralized
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| 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 | electronic health record (EHR)
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| 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 chart | health record
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| 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 | health information
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| Any surgical procedure will generate a report | operative reports
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| As long as a client is alive and has the potential to seek treatment, a health record remains active | disposition
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| Client has specifically asked the doctor to keep confidential | lock boxes
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| Combination of alphabetical or numeric with colour | colour coding
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| Consent must be obtained in order to collect the information | consent form
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| Designate one location in which to house all records | centralized storage
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| Distribution of and access to information is strictly controlled | provision
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| Each client is assigned a unique identifier | identification system
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| 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 | challenging compliance
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| Electronic chart | eChart
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| Growth charts,antenatal records,diabetic flow sheets etc | miscellaneous reports
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| Includes information that may be considered factual or subjective | personal information
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| Information about policies relating to the management of person information must be readily available to the clients | openness
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| Information should be accurate and complete in terms of how it is recorded to facilitate its proper use | accuracy
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| Keep together with most current on top | lab results
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| May be formally prepared or noted on the progress notes | phsical assessment
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| Normally used for records that are pre-numbered | consecutive
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Created by:
shann77
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