The form fields that are selected for each question will determine the quality of a form and the quality of the data you collect in your EHR software. It’s important that you understand each of the different field types to make sure you’re selecting the one that works best for your purposes.
July 4, 1776.
November 22, 1963
November 11, 1918
I bet that as you read each of these dates, your mind conjured a specific image or feeling. Exhilaration and maybe the faint smell of apple pie for July 4, 1776 – the day America declared her independence from England. Shock and the image of Jackie Kennedy’s iconic pink, bloodstained dress for November 22, 1963 – the day President Kennedy was assassinated. Joy and overwhelming relief for November 11, 1918 – the day the Allies of World War 1 and Germany signed the armistice to cease hostilities.
Dates are important…
And not just the ones with historical significance that everyone knows. In a clinical setting, dates represent when a client was last seen or when they last received their medicine. These dates will determine how a clinician proceeds – whether an appointment should be scheduled, or medicine will be administered.
Recording dates in your electronic health record is more complex than it appears. A variety of events entered into an electronic health record are tracked using dates. When a treatment plan begins; when an outcomes measurement was last administered; when a client no longer needs treatment at all can each be used as checkpoints throughout a client’s treatment process.
For example, when assessing a client’s progress, you would want to see how much they’ve improved in between administrations of an outcomes measurement or between the beginning and end of their treatment plan.
To preserve data integrity, dates must be accurately recorded, and they should not be changed once they’re inputted. Your electronic health record should capture many dates automatically and prevent them from being changed afterwards to limit human error. A good example is a signature date as this date can’t be anything other than when the form was signed.
Oh – that’s what it means?
Accurately recording dates won’t be possible at your agency if everyone doesn’t know exactly what they represent. You need to make sure everyone interprets dates the same way and tracks them accordingly to collect the information you need.
For example, two of your clinicians may interpret “Date of Last Contact” differently. You may think that it means the last visit a client had with a clinician, while another may think it means a phone call to re-schedule an appointment. To prevent this, define each of the date fields in your electronic health record and distribute the definitions across your agency. You’ll also want to include an overview of the definitions in your on-boarding process.
Dates are a critical element of data capture – with these tips, you can ensure they’re working for you and preserving your data integrity.