Guidelines for data collection from medical records for use in retrospective analyses

To develop a set of guidelines for medical record data collection. Physician-scientists frequently undertake retrospective clinical data analysis. The patient’s medical record is used as the source of clinical data in this study; however, medical records are meant for patient care and are not systematically maintained for research purposes. To create criteria for data gathering from medical records, we drew on literature suggestions and our own experience with a retrospective cohort study that uses a DNA bank. The guidelines provide several data collection methodologies addressed and demonstrated through examples.  The quality of research data is improved when rules for data gathering are used. A properly-designed case record form and a handbook for uniform data collecting are crucial for data collector training and enabling thorough record searching; yet, certain types of information are not always effectively captured in patient records. As a result, pilot research is required to examine the study design and the usage of supplementary questionnaires. To avoid bias in outcome definition, accurate interpretation of clinical outcomes documented in medical records frequently demands the use of an impartial adjudication committee. For evaluating patient outcomes, data collecting identified fundamental aspects of patient registries. They include data definitions that are specific and consistent for consistently gathering data items for each patient. The case report form (CRF) is the registry’s data format, just as it is in randomized controlled trials. A CRF is a structured set of data components that can be printed or displayed electronically.

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Reference

  1. Angelique C.M. Jansena, Emily S. van Aalst-Cohena, Barbara A. Huttenb, Harry R. Bullera, John J.P. Kasteleina,*, Martin H. Prinsc;  Guidelines were developed for data collection from medical records for use in retrospective analyses, Journal of Clinical Epidemiology 58 (2005) 269–274.
  2. Gliklich RE, Dreyer NA, Leavy MB, Registries for Evaluating Patient Outcomes: A User’s Guide [Internet]. 3rd edition: Agency for Healthcare Research and Quality (US); 2014 Apr.