A new focus on data capture is required like the skill to share electronic health records internally and externally with healthcare organizations and this has been accepted as a way to improve the value of care. Accurate data leads to quality information that is required for quality care and decision making. Inaccurate data threatens patient safety and can lead to increased costs, inefficiencies, and poor financial performances. To ensure the data is accurate it is best to follow the application of documentation guidelines and data standards. The data and information in an EHR must be accurate, complete, concise, and consistent and understood by many if not all data users and must be done in a legal way.
Some practices that are very useful to have the best quality data are role based access, using data dictionaries, using standard format and structured data, following state and federal laws and regulations, and data integrity. Role based access is clearly written policies based on what information access is needed by a specific role or relationship to patient types musty be developed. Data dictionaries are dictionaries that define each information system with standard field definitions for each element. Standard format is being consistent, using standardized templates and online forms. Structured data is very important to follow when sending information, like when you insert data in correctly formatted areas instead of