| A | B |
|---|
| Organizational Practice | A process or strategy used by an organization to maintain or improve data quality. |
| Data Quality Audit (DQA) | An audit used to detect documentation errors, verify reported data, and assess data collection and reporting quality. |
| Continuous Data Quality Improvement | Ongoing efforts to improve the accuracy, reliability, and consistency of data. |
| Discrepancy | A difference or inconsistency found in documentation or data. |
| Reported Data | Data submitted or communicated for organizational, regulatory, or reporting purposes. |
| Audit Report | A report that outlines audit findings, summarizes data quality, and provides improvement recommendations. |
| Recommendation for Improvement | Suggested action to address data quality concerns found during an audit. |
| Data Verification | Checking recorded information against trusted sources to confirm accuracy. |
| Data Validation | Reviewing data for completeness, consistency, and adherence to standards. |
| Trusted Source | A reliable source used to confirm the accuracy of recorded information. |
| Manual Audit | A review of records or data completed by a person rather than an automated system. |
| Double-Entry Verification | A method where data is entered or checked twice to reduce errors. |
| Supporting Document | A document used to confirm or verify recorded information. |
| Automated Check | An electronic check used to identify missing, inconsistent, or nonstandard data. |
| Coding Standard | A standard that guides how codes are assigned to health information. |
| Terminology Standard | A standard that guides the use of consistent health terms. |
| Standardized Form | A consistent template used to capture and record required information. |
| Template | A structured format used to collect information consistently. |
| Uniform Data Capture | Collecting data in a consistent way across records or systems. |
| Data Interpretation | Understanding the meaning of data for analysis or decision-making. |
| Data Analysis | Examining data to identify meaning, patterns, or conclusions. |
| Reliable Data | Data that can be trusted for decision-making and care. |
| Accurate Data | Data that is correct and reflects the true situation. |
| Consistent Data | Data recorded in the same way across records and systems. |
| Data Integrity | Ensuring the accuracy and consistency of information throughout its lifecycle while protecting it from modification or corruption. |
| Information Lifecycle | The stages information passes through from collection to storage, use, archiving, and disposition. |
| Data Collection | The process of gathering or capturing data. |
| Data Storage | Keeping data securely for current or future use. |
| Data Usage | Using data for care, reporting, decision-making, or other approved purposes. |
| Data Archiving | Preserving data for long-term storage or future reference. |
| Error | Incorrect or inappropriate information in a record. |
| Omission | Missing information that should have been recorded. |
| Data Creation | The point at which data is first generated or entered. |
| Data Capture | The process of recording or collecting data. |
| Paper Record Correction | Correcting a paper record by drawing a single line through the error, keeping it legible, and adding initials, date, and corrected information. |
| Single-Line Strikethrough | A correction method where one line is drawn through incorrect paper documentation while leaving it readable. |
| Legible | Clear enough to be read. |
| Authentication | Verification of the user making a change or correction. |
| Original Documentation | The initial record entry, which should remain viewable after corrections are made. |
| Correction Reason | The explanation for why a change or correction was made. |
| Retraction | Removing or flagging patient data that was entered in error while keeping a record of the change. |
| Amendment | A change or addition to existing documentation in the system. |
| Redaction | Selectively obscuring or removing sensitive or confidential information from a document or record. |
| Comment | Additional context, explanation, or clarification added to a record entry or event. |
| Audit Trail | A record that tracks changes, discussions, decisions, or access related to documentation. |
| Access Log | A record showing who accessed a record and related access details. |
| Wrong Patient File | A data integrity problem where information is saved in the incorrect patient's record. |
| Wrong Chart Area | A data integrity problem where information is placed in the wrong section of a patient's chart. |
| Dictated Report | A report created from provider dictation, often corrected using amendments. |
| Sensitive Information | Information requiring protection because it is private, confidential, or identifying. |
| Confidential Information | Information that must be protected from unauthorized access or disclosure. |
| Late Entry | A separate entry made after information was missed or not captured in a timely manner. |
| Addendum | Additional information added later that relates to a previous entry. |
| Information Integrity | The accuracy, reliability, and protection of information in any format. |
| Access to Health Information | An individual's right to access their own personal health records. |
| Personal Health Record (PHR) | A record that allows a patient to access and review their own health information. |
| Disclosure of Health Information | Sharing personal health information with other individuals or organizations. |
| Third Party | A person or organization other than the patient and provider directly involved. |
| Consent | Permission to collect, use, or disclose health information. |
| Legal Exception | A situation where disclosure may occur without consent because it is allowed or required by law. |
| Regulatory Exception | A situation where disclosure may occur under a specific regulatory requirement. |
| Public Health Purpose | A purpose related to protecting or improving the health of the public. |
| Release of Information (ROI) | A process for responding to written requests for health information. |
| Written Request | A formal request submitted in writing for access to or disclosure of information. |
| Processing Fee | A fee that may be charged to process a request and copy information. |
| Access Control | The process that determines who is authorized to access patient information. |
| Physical Security Safeguard | A physical measure, such as locked storage, used to protect records. |
| Logbook | A paper-based tool used to track access to records. |
| Credential | Information used to verify a user’s identity before granting system access. |
| Authorized User | A user permitted to access specific patient information. |
| Access Audit | A review of who accessed a record, when, why, and in what role. |
| Personal Health Information (PHI) | Identifying information about an individual’s health or healthcare. |
| Safeguard | A measure used to prevent unauthorized access, use, or disclosure of information. |
| Secure Electronic System | An electronic system designed to protect health information. |
| Employee Training | Education provided to staff about privacy, security, and proper records management. |
| Confidentiality Agreement | An agreement requiring a person to protect confidential information. |
| Legal Aspects of HIM | Laws and requirements related to confidentiality, privacy, access, disclosure, and records management. |
| Confidentiality | The obligation to keep patient information private and protected. |
| Privacy Legislation | Federal, provincial, or territorial laws that protect personal health information. |
| Federal Privacy Legislation | Privacy law that applies at the federal level in Canada. |
| Personal Information Protection and Electronic Documents Act (PIPEDA) | Federal legislation governing the collection, use, and disclosure of personal information unless similar provincial legislation applies. |
| Provincial Privacy Legislation | Privacy legislation that applies within a province. |
| Personal Health Information Protection Act (PHIPA) | Ontario legislation governing personal health information. |
| Substantially Similar | A designation indicating that provincial privacy legislation is similar enough to PIPEDA. |
| Personal Health Information Privacy and Access Act (PHIPAA) | New Brunswick legislation that includes regulations regarding electronic health records. |
| Security Measure | A measure used to protect data and prevent unauthorized access. |
| Compliance | Following applicable privacy laws, policies, and legal requirements. |
