H.I.M. Review
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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 (PI)
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| A database of all client's registered | master patient index (MPI)
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| A federally funded organization with a mandate to facilitate the national implemantation of electronic health records | 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 (EHR) | 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 that can be added to a computer for access purposes. It displays a randomly generated acecss code that changes every few seconds | fob
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| A system for keeping track of paper health records taken from their normal location | outguiding system/ charge-out 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 ( health record) electronically | electronic medical records system
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| Allows parts of the record to reside outside the 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 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
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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
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| Distribution of and access to information is strickly controlled | provision
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| Each client is assigned a unique identifier | ID systems
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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
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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 sheets
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| May be formally prepared or noted on the progress notes | physical assessment
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| Normally used for records that are pre-numbered | consecutive
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| Occurs each time a client has an encounter with a health-care provider | encounter record
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| Oldest and most straightforward; direct access system | alphabetical
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| Organizing records through some kind of filing system | maintenance
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| Paper chart | pChart
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| PIO who is ultimately responsible for the compliance of the organization with the standards spelled out in the act | accountability
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| Provides a cumulative view of history and current health status | cumulative patient profile (CPP)
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| Questionnaire that the client is asked to fill out on first visit | history (interview) sheet
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| Requires an index; indirect access system | numeric
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| Review and reorganize to remove outdated information that is no longer actively needed to provide care to the client | purge
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| Segments a number into component parts | terminal digit
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| Should be noted in red and listed in a prominent place | list of allergies
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| The initial retrieval of information | creation
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| The organization must take appropriate and practical measures to protect the information from unauthorized access, use or tampering | safeguards
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| To remove a file from active status and store it in a secondary location or on a secondary medium | archive
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| Violates the law and moral and ethical principles | unlawful access
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| With written request to the PIO, clients shall be given access to their personal information | individual access
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| 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
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| 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
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| A | 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, complaints
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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 | outpatient; operative procedure
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| ORTH,orth | 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, r/o | rule out
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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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| STAT, stat | immediately
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| Sx | symptoms
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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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