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review for HiM

Quiz yourself by thinking what should be in each of the black spaces below before clicking on it to display the answer.
        Help!  

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  
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master patient index   A database of all clients registered  
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canada health infoway   A federally funded organization with a mandate to facilitate the national implementation of electronic health records  
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health information management   A field in its own right  
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ehealth   A general term used to describe electronic health information  
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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)  
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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  
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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  
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outguiding system/or changeout system   A system fort keeping track of paper health records taken from their normal location  
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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  
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decentralized   Allows parts of the record to reside outside HIS  
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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  
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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  
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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  
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operative report   Any surgical 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 specifically asked the doctor to keep confidential  
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colour coding   combination of alphabetical or numeric with colour  
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consent form   consent must be obtained in order to collect the information  
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centralized   designate 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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I.D 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 with respect to the way personal information is collected / used or disclosed or the manner in which the organization complies with the legislation  
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echart   electronic chart  
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miscellaneous   growth charts antenatal records, diabetic flow sheets  
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personal information   includes information that may be considered factual or subjective  
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openness   information about policies relating to the management of personal information must be readily available to the clients  
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accuracy   information should be accurate and complete in terms of how it is recorded to facilitate its proper use  
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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 notes  
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consecutive   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 and most straight forward 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 for the compliance of the organization with the standards spelled out in the act  
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cummulative patient profile   provides a cummulative view of history and current health status  
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history (interview) sheet   questionaire that the client is asked to fill out on first visit  
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numeric   requires an index indirect access system  
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purge   review and re-organize to remove outdated information that is no longer actively needed to provide care to the client  
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terminal digit   segments a number into component parts  
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list of allergies   should be noted in red and listed in a prominent place  
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creation   the initial retrieval of information  
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safeguards   the organization must take appropriate and practical measures to protect the information from unauthorized access, use or tampering  
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archive   to remove a file from active status and store it in a secondary location or a secondary medium  
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unlawful access   violates the law and moral and ethical principles  
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individual access   with written request to the PIO clients shall be given access to their personal information  
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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  
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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  
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A&P   auscultation and percussion  
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ADLs   activities of daily living  
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BP, B/P   blood pressure  
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Bx   biopsy  
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c/o   complains of,  
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CC   chief complaint  
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CPX   complete physical examination  
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Dx   diagnosis  
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EMR   electronic medical record  
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FH   family history  
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Fx   fracture  
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HPI   history of present illness  
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Hx   history  
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LMP   last menstrual period  
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MRP   most responsible physician  
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MS   mental status  
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OP   out patient; operative procedure  
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ORTH, ortho   orthopedics  
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PCP   primary care physician  
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PE   physical examination  
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PMH   past medical history  
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R/O   rule out  
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Rx   prescription  
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SOAP   subject, objective, assessment, plan  
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SOB   shortness of breath  
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STAT   immediately  
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Sx   symptom  
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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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