Health Information Privacy, Security, and Medical Records (Alberta) - Vocabulary flashcards

Vocabulary cards covering key terms related to health information privacy, security, and dental records management drawn from Week 1–Week 8 notes.

Health Information Act (HIA)

Alberta law governing the collection, use, and disclosure of health information by custodians and their affiliates.

Custodian

Health service providers or organizations named in the HIA that hold and manage health information.

Affiliate (HIA)

Anyone employed by a custodian (staff, volunteers, students, contractors) who has access to health information.

Privacy

The right of individuals to control how their personal health information is collected, used, and disclosed; governed by privacy legislation.

Confidentiality

The obligation to protect information entrusted to a person or organization from unauthorized disclosure.

Codes of Ethics - CADA

CADA guidelines outlining dental assistants’ duties to patients and compliance with privacy, confidentiality, and human rights laws.

Standards of Practice - CADA/ADA

Standards requiring dental assistants to understand the Health Information Act and custodian policies for protecting patient information.

Patient Registration Form

Form collecting basic patient details: full name, address, phone, date of birth, employment, spouse, insurance, payer, and signatures.

Medical and Dental History Forms

Forms containing current and past medical and dental health information about the patient.

Disclosure

Release or sharing of health information for a purpose other than the one for which it was collected.

Collection and Use

Using patient information only for the originally collected purpose; consent is needed for other uses.

HIA Custodians

Health service providers named in the HIA who hold health information.

HIA Affiliates

Employees, volunteers, students, and contractors affiliated with a custodian who may access health information.

Privacy Legislation

Laws governing how personal information, including health data, is collected, used, and disclosed.

HIPAA

Health Insurance Portability and Accountability Act; U.S. privacy law governing health information privacy and security.

Radiographic Exam

Dental imaging: intraoral images (periapical, bitewing, occlusal) and extraoral images (panoramic, cephalometric, tomography).

Intraoral Examination

Exam inside the mouth including charting of periodontal conditions, chief complaints, and occlusal evaluations.

Extraoral Examination

Exam outside the mouth, including temporomandibular joint findings.

Physical Examination

Assessment components such as growth and development, vital signs, cognition, and communication ability.

Treatment Plan

Record of the plan of care, properly sequenced to address identified problems; may change with finances.

Informed Consent

Consent for a specific treatment or procedure, including expected outcomes and potential complications.

PARTS

Progress Notes framework: Problem, Assessment, Recommendation, Treatment, Strategy.

Progress Notes

Records of treatment with date, tooth, procedures completed, and patient communications.

Chart Entries

Rules for charting entries; legibility, order, and late-entry policies.

Handwritten Records

Paper records that must be legible; late entries must be cross-referenced and dated; corrections require a single-line strike and signature.

Infection Control for Paper Records

Protocols to prevent contamination of paper records during patient care.

Digital Records / EHR

Electronic Health Records; longitudinal, real-time records accessible to authorized personnel.

Password Protection

Security measure restricting access to digital health information.

Audit Logs

Records that track who accessed or modified health information.

Off-site Backups

Backups of digital records stored at a location separate from the primary site.

Role-based Access

Access permissions determined by a user's role within the healthcare organization.

Privacy Screens

Tools or measures to maintain confidentiality when viewing or entering data.

FOIP Act

Freedom of Information and Protection of Privacy Act (Alberta); historically governed privacy and access, superseded in 2025 by PPA/ATI acts.

PIPA

Personal Information Protection Act; provincial private-sector privacy law (Alberta/BC).

PIPEDA

Personal Information Protection and Electronic Documents Act; federal privacy law for the private sector.

ATI Privacy Protection Act / ATI Act

Alberta act related to access to information and privacy (current framework referenced in notes).

PPA

Personal Privacy Act; Alberta privacy legislation replacing FOIP for provincial private-sector privacy.

Health Professions Act (HPA)

Alberta statute regulating health professions and governing regulatory bodies (colleges) in Alberta.

Colleges (Regulatory Bodies)

Self-governing bodies such as the College of Dental Assistants of Alberta, Alberta Dental Association and College, and College of Registered Dental Hygienists of Alberta.

Retention of Patient Records

Adults: minimum 10 years after the last service; minors: 10 years past the age of majority.

Chairside Notes

Notes entered during patient care at the chairside.

Amendments

Corrections or updates to digital chart entries following proper procedure.