Documentation Standards
only the authoring provider or authorized delegate, following proper amendment procedures.
Who can amend a signed note
The obligation upon an organization or person to protect information that has been entrusted to its care for a specific purpose and to ensure that information is only accessible to those authorized to have access.
What is confidentiality.
Delegated by SJH, the operational responsibility for ensuring management of health records (paper-based and electronic) in accordance with all legislative requirements.
What is the Health Information management Department
Only the HIM department can provide copies of this type of health record
What is a legal/official health record.
A condition that can be described as being the most responsible for a patient's admission/visit
What is the Main Diagnosis Code or MRDx
A diagnosis and signature
What QA looks for in an UCC visit audit.
Public Health Reporting, Patient Safety concerns and legal requirements
When can PHI be shared with out explicit patient consent
a person who is authorized to give or refuse consent to a treatment on behalf of a person who is incapable with respect to the treatment
Who is the "Substitute Decision Maker"
The amount of time in which a health information custodian is required to respond after receiving a request for access to personal health information
What is 30 days
the process of transforming information related to diagnoses and/or procedures into standardized alphanumeric codes used in funding, decision support and reported to healthcare data bases.
What is medical coding
these include Accuracy, timeliness, completeness, legibility, and authenticity
What are documentation quality indicators
its' purpose is to record user access, edits, and actions for accountability and data integrity.
What is an audit trail
A member within the meaning of the Regulated Health Professions Act, 1991 and who provides health care.
What is a Health Care Practitioner
These requests do not require expressed/explicit consent and are processed free of charge
What are Circle of Care requests?
Medical term for ringing in the ear(s)
What is tinnitus
Refers to specific documents included as part of the deficiency tracking process, including documents created both in electronic and paper-based format
What are "Tracked Documents"
these can include disciplinary action, fines, and reporting to privacy commissioners.
What are possibly penalties for privacy breaches
A person or organization who has custody or control of personal health information as a result of or in connection with performing the person’s or organization’s powers or duties
What is a Health Information Custodian (HIC)
The age at which an individual is considered capable of consenting to the collection, use or disclosure by a health information custodian of personal health information about the individual as per PHIPA.
What is 16 years of age
These impact case mix grouping (CMG) assignment, Resource Intensity Weight (RIW) and complexity
What are co-morbidities
These documents include Death Certificate, Notification of Death, Death Summary, Discharge Summary, Intervention/Procedure Reports, Anesthesia Record, emergency Record Diagnosis, Emergency Record signature, Admission/History and Physical
What are St. Joseph's healthcare London deficiency tracked documents
Typically 10 years from the date of last entry (per jurisdictional or facility policy)
What is the minimum retention period of "patient records"
the "owner" of the personal health information contained in the record.
Who is the patient
The evidence of their legal role an individual is required to present when requesting records on behalf of a deceased patient.
What is proof of estate trustee/executor status (or legal authority)?
a terms for the drainage of the anterior chamber (of eye) accomplished from inside the eye
What is ab interno