CHPCN(C) flashcards
CHPCN(C) · Build recall with a focused review session.
32 cards. Read the term and the definition here. The deck at the top of this page is optional.
- Health record definition
- The primary legal and clinical record of a patient's care, maintained by the organization and containing documentation of assessments, interventions, and outcomes in paper or electronic form.
- Quantitative record analysis
- A review that checks whether required forms, signatures, dates, and fields are present and complete, without judging the clinical content of the documentation.
- Qualitative record analysis
- A review that evaluates whether documentation content supports the diagnosis, justifies the care provided, and reflects the patient's condition and response to treatment.
- Record retention schedule
- A policy and legislated framework specifying how long health records must be kept, typically based on time since last encounter and special rules for minors.
- Addendum correction method
- A dated, signed entry added to the record to correct or clarify earlier documentation; the original entry remains visible and is never obliterated or deleted.
- Release of information
- The authorized disclosure of health information to a requesting party, requiring verification of identity, valid consent or legal authority, and logging of the disclosure.
- CHIM credential
- The Certified Health Information Management designation awarded by the Canadian Health Information Management Association, demonstrating competence in health information practice.
- Chart deficiency process
- A tracking system that identifies incomplete records, notifies responsible clinicians, and monitors completion against timelines set in medical staff bylaws.
- Discharge summary content
- A record entry summarizing the reason for admission, significant findings, procedures performed, discharge diagnoses, medications, follow-up plan, and condition at discharge.
- ICD-10-CA
- Canada's classification system for diagnoses and morbidity, maintained by CIHI, used to code conditions in acute care and other reporting databases.
- CCI
- The Canadian Classification of Health Interventions, maintained by CIHI, used to code procedures and interventions performed during care episodes.
- SNOMED CT
- A comprehensive, multilingual clinical terminology with concepts and relationships that enables consistent recording and semantic exchange of clinical information across systems.
- LOINC
- A standard terminology for identifying laboratory tests and clinical observations, enabling comparable results to be exchanged between systems and laboratories.
- HL7 FHIR
- A modern health interoperability standard using resources and application programming interfaces to exchange clinical and administrative data between systems.
- Data quality dimensions
- Attributes used to assess data, commonly accuracy, completeness, consistency, timeliness, validity, and uniqueness, each measurable against defined thresholds.
- Discharge Abstract Database
- A CIHI national database containing abstracted clinical, demographic, and administrative data for inpatient hospital discharges, used for reporting and case mix.
- Case Mix Group Plus
- CIHI's inpatient grouping methodology that assigns discharges to clinically and resource-similar groups using coded diagnoses, interventions, and patient characteristics.
- Personal health information
- Identifiable information about an individual's physical or mental health, care received, or payment for care, in any format including paper, electronic, and verbal.
- Circle of care
- The principle allowing health information to be shared among providers currently involved in a patient's care, generally without additional express consent.
- Implied consent
- Consent inferred from the patient's circumstances and expectations, commonly applied to sharing information within the treating care team rather than outside it.
- Lockbox request
- A patient's request to restrict access to specific health information; clinicians must apply it while considering safety obligations and applicable legal requirements.
- Privacy breach notification
- The process of containing a breach, assessing risk of harm, and notifying affected individuals and the regulator where legislation sets notification thresholds.
- Right of access
- A patient's legal right to view and obtain copies of their health record, subject to limited exceptions such as significant harm or third-party information.
- Minimum necessary principle
- The rule that only the least amount of health information needed for a purpose should be collected, used, or disclosed, limiting unnecessary exposure.
- Privacy impact assessment
- A structured review conducted before a new system or data flow is implemented, identifying privacy risks and the safeguards needed to mitigate them.
- PIPEDA
- Canada's federal private-sector privacy law applying to personal information, including health information, collected during commercial activity, with provincial laws sometimes replacing it.
- Semantic interoperability
- The ability of systems to exchange data and interpret its meaning consistently, requiring shared terminologies and models rather than only matching message formats.
- Data warehouse
- A consolidated repository that integrates data from multiple source systems for reporting and analysis, supported by documented definitions and metadata.
- Descriptive analytics
- The analytics tier that summarizes what happened, using counts, rates, trends, and dashboards to describe past performance and current status.
- Predictive analytics
- The analytics tier that uses historical data and statistical or machine learning models to estimate the likelihood of future events such as readmission.
- Length of stay indicator
- A measure of days a patient spends in hospital, calculated from defined admission and discharge dates, with in-day and alternate level of care rules applied consistently.
- Role-based access control
- A security method granting system permissions according to a user's job role, combined with audit logging to detect inappropriate access to health information.