Clinical Method
Research strategies that result in optimal data collection from the patient medical record

https://doi.org/10.1016/j.apnr.2010.02.004Get rights and content

Abstract

Data obtained from the patient medical record are often a component of clinical research led by nurse investigators. The rigor of the data collection methods correlates to the reliability of the data and, ultimately, the analytical outcome of the study. Research strategies for reliable data collection from the patient medical record include the development of a precise data collection tool, the use of a coding manual, and ongoing communication with research staff.

Introduction

The patient medical record is a rich source of data frequently used by nurses conducting clinical research (Gearing et al., 2006, Gregory, 2007, Halm et al., 2009, Johnson et al., 1998, Jones & Fennie, 2007). The patient medical record is often used as a primary source of retrospective data for the purposes of epidemiological analysis and is considered to be the gold standard in any study to identify demographic factors, clinical data variables, specific aspects related to treatment regimens, and ultimately patient mortality and morbidity (Cassidy et al., 2002, Murray et al., 2003). Data collection from the medical record involves reviewing specific sources within the record. These include nursing, physician, and consultation notes; admission and discharge reports; laboratory and diagnostic test reports; surgical reports; and other clinical and administrative documentation. This is not easily done. A sound strategy prior to initiating the data collection effort is required. This article provides a description of strategies that may be implemented to ensure optimal data collection from the medical record. These research strategies have been tested and successfully demonstrated in both retrospective and prospective data collection efforts (Eder et al., 2005, Gearing et al., 2006, Pan et al., 2005). The proposed strategies will provide nurse investigators with specific methods that will contribute to the successful collection of data from the patient medical record by research staff using a data collection tool.

Section snippets

The utility of patient medical record data in clinical research

Patient medical record data collected via retrospective chart review contribute to at least 25% of the scientific articles published in clinical journals (Gilbert et al., 1996, Murray et al., 2003, Worster & Haines, 2004). Retrospective medical record review is a useful methodology in exploring research questions that often cannot be answered using prospective trials. These questions may include the study of potentially harmful effects of exposures, as well as the occurrence of rare events in

Collecting patient medical record data for research

Protocols and guidelines for data abstraction from the medical record must be developed prior to launching any medical record data collection effort. Strategies underpinning these protocols and guidelines include (a) the development and testing of a data collection tool; (b) the use of a coding manual guiding data collection of specific variables from the medical record; and (c) the selection, training, management, and ongoing communication with research staff (i.e., data abstractors). The

Conclusion

The patient medical record has long been recognized as a rich source of information for conducting clinical research. However, investigators must take a strategic approach to data collection efforts and implement a rigorous methodology when conducting prospective and retrospective clinical studies that utilize the data available in the medical record (Faster Cures: The Center for Accelerated Medical Solutions, 2004). A strategic approach to conducting retrospective chart reviews in clinical

References (37)

  • BatesM.C. et al.

    Factors influencing the need for target vessel revascularization after renal artery stenting

    Journal of Endovascular Therapy

    (2006)
  • BattleC.L. et al.

    Clinical characteristics of perinatal psychiatric patients: A chart review study

    Journal of Nervous and Mental Disease

    (2006)
  • BernardM. et al.

    A comparison of popular online fonts: Which size and type is best?

    Usability News

    (2002)
  • BiedermanJ. et al.

    Aripiprazole in the treatment of pediatric bipolar disorder: A systematic chart review

    CNS Spectrums

    (2005)
  • BurtC.W. et al.

    Electronic medical record use by office-based physicians: United States, 2005

  • CassidyL.D. et al.

    Methodology to improve data quality from chart review in the managed care setting

    American Journal of Managed Care

    (2002)
  • Colón-EmericC. et al.

    Translating evidence-based falls prevention into clinical practice in nursing facilities: Results and lessons from a quality improvement collaborative

    Journal of American Geriatric Society

    (2006)
  • CoyneC.A. et al.

    Randomized, controlled trial of an easy-to-read informed consent statement for clinical trial participation: A study of the Eastern Cooperative Oncology Group

    Journal of Clinical Oncology

    (2003)
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