| A | B |
|---|
| Health Record | Confidential, systemic compilation of an individual's health history (can be a single document or a collection - there is no specific legal definition) |
| Paper-Based Record | A health record that exists in physical paper form and is organized as a single patient health record. |
| Electronic Record | A digital health record that organizes information by encounter and document type, usually in chronological order. |
| Hybrid Record | Combination of both paper or scanned patient information and digital patient information |
| Encounter | A specific interaction or visit between a patient and a healthcare provider or organization. |
| Document Type | A category used to organize health record documents, such as laboratory results, physician notes, or imaging reports. |
| Chronological Order | Organization of information according to the date and time it was created or received. |
| Advanced Directive | A legal tool that allows individuals to plan for situations where they become unable to make or communicate healthcare decisions. |
| Terminal Digit Order | A filing system in which the last digit or group of digits in the health record determines file placement. |
| Storage | The process of keeping health records in a secure and organized location or system. |
| Record Storage Space | Physical space required to store paper records, such as shelves, filing cabinets, or boxes. |
| Organizational Requirements | Professional rules, policies, procedures, mandates, and legislation that guide how patient information is organized and managed. |
| Information Exchange | The sharing of accurate health information between authorized people, departments, or systems. |
| Access Controls | Safeguards that limit who can view, use, or manage health information. |
| Privacy Controls | Policies and measures that protect personal health information from inappropriate use or disclosure. |
| Security Measures | Processes and tools used to protect records from unauthorized access, loss, damage, or misuse. |
| Compliance | Following relevant regulations, accreditation standards, professional guidelines, policies, and legislation. |
| Accreditation Standards | Standards used to assess whether an organization meets accepted quality and safety requirements. |
| Professional Practice Guidelines | Recommended practices that guide professionals in properly managing health information. |
| Retention | The process of storing inactive health records and making them available for future use; in compliance with government regulations. |
| Retention Period | The total length of time health data must be kept. |
| Record Retention Schedule | A plan identifying what information is kept, how long it is kept, and in what format it is stored. |
| Inactive Health Record | A health record that is no longer in regular active use but must still be stored and available if needed. |
| Risk Management | Processes used to identify, reduce, and manage risks to health information and records. |
| Disaster Recovery | Processes used to restore access to health records and protect information during or after an emergency. |
| Data Backup | The process of copying information so it can be restored if data is lost or damaged. |
| Emergency Response Procedures | Steps used to respond to emergencies that may threaten access to or integrity of records. |
| Continuity Planning | Planning that helps an organization continue essential operations during disruptions. |
| Downtime Procedures | Procedures that direct staff in accessing and maintaining patient information during computer or communication outages. |
| Redundant Systems | Intentional duplication of core information or systems to improve reliability and operability. |
| Authentication Procedures | Processes used to verify the identity of users accessing health information. |
| Destruction of Records | The secure disposal of records at the end of their retention period or when another approved copy exists. |
| Active Record | A record currently used for ongoing patient care or administrative purposes. |
| Duplicate Information | Repeated copies of information that may be destroyed regularly according to policy. |
| Authorization and Verification | Approval and confirmation required before destroying medical records. |
| Secure Destruction Method | A confidential method used to destroy records and prevent unauthorized access. |
| On-Site Shredding | A common secure destruction method where paper records are shredded at the organization. |
| Incineration | A confidential destruction method that destroys records by burning. |
| Confirmation of Destruction | Documentation verifying that records were destroyed using an approved method. |
