Data Capture, Standards And The EHR Paper

Data capture, standards and the EHR. HIM practices revolve around information stewardship and data governance. Data governance includes an “inventory of the organization's resources and how they are managed, organized, and controlled, as well as the process for the application of the rules to the applicable information resources in the information inventory” (AHIMA, 2011). Data standardization is an element in data stewardship that affects the use of data for quality and patient safety programs.
Numerous roles and responsibilities are emerging as data is being standardized across organizational systems. “HIM professionals are experts in data content standardization and have the necessary skills and competencies to advance improved validation, capture, analysis, and output of information for quality and patient safety initiatives” (AHIMA, 2011). As the industry shift towards

HIM professionals have also become involved with managing the use of vocabularies and clinical code sets within their organization. While traditionally this has primarily revolved around code sets for diagnosis and procedure classifications such as ICD and CPT, the evolution of the EHR and the increasing use of other clinical data such as laboratory results and drugs will increase the types of code sets that will need to be managed.
Accurate data assignment, capture, analysis, and trending of healthcare operations for decision making has evolved in the HIIM field to facilitate the aggregation of data from multiple sources to enable the capture of data once so it can be repurposed many times. Capturing information that supports a more accurate measurement of healthcare quality, such as determining how adverse events (i.e., injuries caused by medical management, not the underlying disease) actually occur in hospitals is just one