There are multiple ways to Capture a Data Element. Once we capture the Data Elements we will need to verify the information we captured with the information on the Medical Record in the Data Element Review Box.
There are two options for capturing the Data Elements:
- Area Highlight (Yellow): Default method for highlighting a Data Element, this will highlight a block of information
- Select Text (Blue): This option highlights just the text and should yield the same results as the Area Highlight.
Rules for Capturing and Editing Data Elements
- Avoid Capturing Bullets points when possible. If it is unavoidable, it is acceptable to capture and save a Data Element as is.
- Remove Special Characters. When reviewing what was captured, remove any special characters that appear in the Data Element Review Box, that are not on the Medical Record.
- Fix necessary spelling errors, this includes; medical terminology, adjectives and nouns pertaining to medical terms, names, and Facility/Provider. We do not need to fix words such as ‘the’, ‘of’, ‘in’, and other preposition words or non-medical terms.
- Do not need to adjust spacing. The spacing that occurs between words does not need to be adjusted, we only need to adjust the spacing if an unnecessary space is present within a word or we need to add a space to separate words.
- Jumbled Text, when a Data Element is captured and the lines of text are not aligned with the medical record we will need to fix the text to be more aligned with the text on the medical records. For Example, the 1st line of text is appearing as the 3rd line of text in the Data Element Review Box. Report to leadership if this happens.
- Missing Text, we can attempt to recapture the Text by widening the are we capture. When applicable, we can try highlighting a little wider and higher, typically this method will include the missing text. If it is still not visible after 2nd attempt, please type in the text if it contains any medical information.
- Do not summarize or change the data from the medical record. We need to leave the integrity of the record intact.
How to Capture a Data Element
- Select preferred Highlight Tool
- Using the Left Button on your mouse, click and highlight the text you would like to capture
- Once the area you have selected is yellow/blue, release the left button on the mouse and right-click within the highlighted area.
- Select a Data Element