CHPCN(C) key terms

A documented account of a patient's care, kept by a provider, that records assessments, treatments, test results, and outcomes over time and supports clinical decisions and continuity of care.

A person or organization with legal responsibility for protecting and managing personal health information, such as a hospital, physician, laboratory, or long-term care home.

Identifying information about an individual's physical or mental health, care received, health provider, or payment for care, whether recorded or not, that is protected by privacy law.

The principle that only the least amount of health information needed for a purpose should be collected, used, or disclosed, limiting exposure and reducing privacy risk.

A patient's informed agreement to the collection, use, or disclosure of their health information, which must be voluntary, specific, and given by someone with capacity or their substitute decision-maker.

A person's ability, at the time a decision is needed, to understand information relevant to a health decision and appreciate the reasonably foreseeable consequences of making it.

A person legally authorized to make health information or treatment decisions on behalf of someone who lacks capacity, ranked according to rules set by provincial or territorial law.

The informal concept describing health team members who need a patient's information to provide care; it is not itself a legal authority and must be grounded in law or consent.

An access control principle permitting staff to view only the health information required for their assigned duties, preventing casual or curiosity-driven browsing of patient records.

A request by a patient to restrict access to specific parts of their health record, withdrawing implied or general consent for those portions, subject to safety and legal limits.

The act of making personal health information available to a person or organization outside the custodian, including sharing records with third parties, insurers, or other providers.

A process that removes or alters identifiers so health information can no longer reasonably be linked to an identifiable individual, reducing privacy obligations while preserving analytic value.

Health information combined across many individuals and reported in summary form, such as counts or rates, so that no single person's data can be identified.

The degree to which health data are accurate, complete, timely, consistent, and fit for their intended use, affecting clinical decisions, reporting, and research reliability.

A reference document defining each data element in a system, including its name, definition, format, permitted values, and source, supporting consistent interpretation and interoperability.

The smallest named unit of data with a defined meaning and format, such as admission date or blood pressure, that can be collected, stored, and exchanged.

An agreed specification for how health data are structured, coded, and exchanged so that different systems and organizations can interpret and share information consistently.

A controlled vocabulary or coding system, such as SNOMED CT or ICD, that assigns standard codes and meanings to clinical concepts to support consistent recording and reporting.

The ability of different health information systems to exchange data and allow the receiving system to use that data meaningfully, enabled by shared standards and interfaces.

A system or organization that enables electronic sharing of patient health information among providers, laboratories, and other authorized users across different care settings.

A digital, longitudinal record of a patient's health information that is created, managed, and shared across authorized care providers to support coordinated, continuous care.

A digital record maintained by a single practice or organization documenting care for its own patients, typically narrower in scope than a shared electronic health record.

Software functions that present alerts, reminders, guidelines, or order sets at the point of care to help clinicians make evidence-informed decisions and reduce errors.

Reduced clinician responsiveness to safety alerts caused by too many frequent or low-value warnings, which can lead to important alerts being ignored.

The extent to which a health information system can be used by intended users to achieve goals effectively, efficiently, and with satisfaction, minimizing errors and unnecessary effort.

A chronological log that records who accessed or changed health information, when, and from where, supporting privacy investigations, security monitoring, and accountability.

Technical and administrative safeguards that determine who may view or use health information, including user authentication, permissions, and role-based restrictions.

A security model that grants system permissions according to a user's job role, so staff can reach only the functions and data their responsibilities require.

Unauthorized access, collection, use, disclosure, copying, modification, or disposal of personal health information, which may require notification to affected individuals and regulators.

The process of converting health information into a coded form that cannot be read without a decryption key, protecting data in transit and at rest from unauthorized viewing.

Measures such as passwords, firewalls, encryption, staff training, and physical locks that protect health information from loss, theft, unauthorized access, or alteration.

A documented plan specifying how long each type of health record must be kept and how it should be destroyed, based on legal, clinical, and operational requirements.

Approved methods, such as cross-cut shredding or certified digital wiping, that render health information unreadable so it cannot be reconstructed or misused after disposal.

A directive requiring an organization to preserve records relevant to litigation, investigation, or audit, suspending normal destruction until the matter is resolved.

The group of records a provider uses to make decisions about individuals, which patients generally have a right to access and amend under privacy legislation.

A patient's formal request to view or obtain a copy of their health information, which custodians must respond to within legislated timelines and with limited exceptions.

A patient's request to amend inaccurate or incomplete health information, requiring the custodian to correct the record or attach a statement of disagreement.

The systematic examination of health data using statistical and computational methods to identify patterns, measure performance, and inform planning and quality improvement.

A measurable value, such as a rate or ratio, used to monitor a defined aspect of health care quality, safety, access, or efficiency over time and against benchmarks.

A visual display that presents key indicators and trends in a consolidated format, allowing managers and clinicians to monitor performance and make timely decisions.

The representation of data through charts, graphs, maps, or other visuals that make patterns and comparisons easier to interpret for decision-making audiences.

Techniques that use historical health data and statistical models to estimate future events, such as readmission risk, supporting proactive planning and targeted interventions.

Systematic error in an analytic model that produces unfair or inaccurate results for certain groups, often because of unrepresentative data or flawed assumptions.