Purple Module Word Scramble
|
Embed Code - If you would like this activity on your web page, copy the script below and paste it into your web page.
Normal Size Small Size show me how
Normal Size Small Size show me how
Question | Answer |
A clear link must be established between the information that is collected and the reason for doing so | limiting collection of personal information (PI) |
A database of all client's registered | master patient index (MPI) |
A federally funded organization with a mandate to facilitate the national implemantation of electronic health records | Canada Health Infoway |
A field in its own right | health information management (HIM) |
A general term used to describe electronic health information | eHealth |
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 (EHR) | electronic medical record (EMR) |
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 |
A small security device that can be added to a computer for access purposes. It displays a randomly generated acecss code that changes every few seconds | fob |
A system for keeping track of paper health records taken from their normal location | outguiding system/ charge-out 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 | electronic medical records system |
Allows parts of the record to reside outside the HIS | decentralized |
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) |
Any documentation relating to a ehalth-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's chart | health record |
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 |
Any surgical procedure will generate a report | operative reports |
As long as a client is alive and has the potential to seek treatment, a health record remains active | disposition |
Client has specifically asked the doctor to keep confidential | lock boxes |
Combination of alphabetical or numeric with colour | colour coding |
Consent must be obtained in order to collect the information | consent form |
Designate one location in which to house all records | centralized |
Distribution of and access to information is strickly controlled | provision |
Each client is assigned a unique identifier | ID systems |
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 |
Electronic chart | eChart |
Growth charts, antenatal records, diabetic flow sheets, etc... | miscellaneous |
Includes information that may be considered factual or subjective | personal information |
Information about policies relating to the management of person information must be readily available to the clients | openness |
Information should be accurate and complete in terms of how it is recorded to facilitate its proper use | accuracy |
Keep together with most current on top | lab sheets |
May be formally prepared or noted on the progress notes | physical assessment |
Normally used for records that are pre-numbered | consecutive |
Occurs each time a client has an encounter with a health-care provider | encounter record |
Oldest and most straightforward; direct access system | alphabetical |
Organizing records through some kind of filing system | maintenance |
Paper chart | pChart |
PIO who is ultimately responsible for the compliance of the organization with the standards spelled out in the act | accountability |
Provides a cumulative view of history and current health status | cumulative patient profile (CPP) |
Questionnaire that the client is asked to fill out on first visit | history (interview) sheet |
Requires an index; indirect access system | numeric |
Review and reorganize to remove outdated information that is no longer actively needed to provide care to the client | purge |
Segments a number into component parts | terminal digit |
Should be noted in red and listed in a prominent place | list of allergies |
The initial retrieval of information | creation |
The organization must take appropriate and practical measures to protect the information from unauthorized access, use or tampering | safeguards |
To remove a file from active status and store it in a secondary location or on a secondary medium | archive |
Violates the law and moral and ethical principles | unlawful access |
With written request to the PIO, clients shall be given access to their personal information | individual access |
You 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 serves its intended purpose; information must be appropriately stored and destroyed | limiting use, disclosure, and retention |
You must inform the clients of the purpose for the collection of their information either before or at the time of the collection | identifying purposes |
A | auscultation and percussion |
ADLs | activities of daily living |
BP, B/P | blood pressure |
Bx | biopsy |
c/o | complains of, complaints |
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 | outpatient; operative procedure |
ORTH,orth | orthopedics |
PCP | primary care physician |
PE | physical examination |
PMH | past medical history |
R/O, r/o | rule out |
Rx | prescription |
SOAP | subjective, objective, assessment, plan |
SOB | shortness of breath |
STAT, stat | immediately |
Sx | symptoms |
WD | well-developed |
WN | well-nourished |
WNL | within normal limits |
Created by:
DawnLangridge
Popular Medical sets