Health Infornmation Mgmt Review
Quiz yourself by thinking what should be in
each of the black spaces below before clicking
on it to display the answer.
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| Limited collection of personal information (PI) | a clear link must be established between the information that is collected and the reason for doing so.
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| Master Patient Index (MPI) | a database of all clients registered
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| Cdn Health Infoway | A federally funded organization with mandate to facilitate the national implementation of electric health records
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| Health Information Management (HIM) | a field in its own right
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| E Health | a general term used to describe electronic health information
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| Electronic Medical Record (EMR) | a legal health record in digital format. Contains clients health information collected by providers in one location. Is a subset of electronic health record (EHR)
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| Health Information Custodian | a person(s) or organization who has the responsibility for safekeeping and controlling personal health information
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| FOB | a small security device that can be added to a computer for access purposes, displays randomly generated access code that changes every few seconds
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| Outguiding System /Change Out System | a system for keeping track of paper health records taken from their normal location
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| Electronic Medical Records Systems | a total medical office system including both HW and SW, capable of replacing all components of a paper charting system.
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| decentralized | allow parts of the record to reside outside HIS
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| Electronic Health Records (EHR) | a accumulation of essential information from an individuals EMR that is accessed electronically at different points of service for purposes of client care
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| Health Record | any document relating to a health-care client. Can be single document or collection of documents
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| Health Information | any information pertaining to someone's physical or mental health condition, or infirmity whether given orally or recorded in any manner.
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| Operative Reports | any surgical procedures will generate a report
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| disposition | as long as a client is alive and has the potential to seek treatment, a health record remains active
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| lock boxes | client has specified to doctor to keep all information confidential
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| colour coding | combination of alphabetical or numeric filing system with coloured tabs
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| consent form | consent must be obtained in order to collect information
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| centralized storage | designated one location in which to house all records
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| provision | distribution of an access to information is strictly controlled
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| Identification Systems | each client is assigned a unique identifier
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| Challenging Compliance | each organization must have a process in place to handle complaints which complies with gov't legislation
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| eChart | electronic chart
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| miscellaneous (charting) | growth chart, antenatal charts, diabetic flow sheets etc.
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| personal information defined | includes information that maybe considered factual or subjective
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| openess | information about policies relating to the management of persons information must be readily available to the client
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| accuracy | information should be accurate and complete in terms of how it is recorded to facilitate its proper use (PIPEDA)
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| lab sheets | keep together with most current on top
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| physical assessment | maybe formally prepared or noted on the progress report
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| consecutive (numeric) | filing systems normally used for records that are pre-numbered
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| Encounter Record | occurs each time a client has an encounter with a health-care provider
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| alphabetical | oldest most straight forward flying system; direct access system
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| maintenance | organizing records through some kind of filing system
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| pChart | paper chart
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| accountability | PIO who is ultimately responsible of the compliance of the organization with standards spelled out in the act (PIPEDA)
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| cumulative patient profile (CPP) | provides a cumulative view of history and current health status
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| history (interview) sheet | questionnaire that the client completes on first visit
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| numeric | filing system require index; indirect access system
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| purge | review and reorganize to remove outdated information that is no longer actively needed in a client's chart
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| terminal digit | filing system with segments of numbers divided into component parts
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| list of allergies | should be noted in red and listed in a prominent place on history sheet
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| creation | initial retrieval of information
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| safe guard | organization must take appropriate and practical measures to protect the information from unauthorized access, use or tampering
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| archive | remove a file from active status and store it in a secondary location
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| unlawful access | violates the law and moral and ethical principles (PIPEDA)
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| individual access | with written request to the PIO, clients shall be given access to their personal information (PIPEDA)
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| limiting use, disclosure, and retention | 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 servers its intended purpose. Must be appropriately stored and destroyed. (PIPEDA)
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| identifying process | you must inform the clients of the purpose for the collection of their information either before or at the time of the collection (PIPEDA)
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Created by:
amatt
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