Optimal data gathering from the patient medical record is the goal of research initiatives

Reviewing particular sources within the medical record is required for data collecting. Nursing, physician, and consultation notes, admission and discharge reports, laboratory and diagnostic test reports, surgery reports, and other clinical and administrative paperwork are included. This is not an easy task. Before beginning the data collection effort, you must have a solid strategy in place. This article describes tactics that can be used to guarantee that data from the medical record is collected as efficiently as possible. Both retrospective and prospective data gathering efforts have successfully proved the effectiveness of these research methodologies. Nurse investigators did clinical research frequently, including data gathered from the patient’s medical record. The rigour of the data collection procedures is related to the data’s reliability and, ultimately, the study’s analytical output. Developing a precise data collecting tool is one of the research methodologies for trustworthy data gathering from the patient medical record.  

The medical record has long been regarded as a valuable source of data for clinical research. When conducting prospective and retrospective clinical studies that use data from the medical record, investigators must take a strategic approach to data gathering activities and use a rigorous methodology. A deliberate strategy to conduct retrospective chart reviews in clinical nursing research will generate high-quality data and reliable outcomes. The development and testing of a data collecting instrument, a coding manual to guide data collection was specific variables from the medical record, and the selection, training, and management of a research team of data abstractors are all tactics suggested in this academic.

Reference:

1. Katherine E. Gregory, PhD, RN^a* and Lucy Radovinsky, MSN, RN^b, Research strategies that result in optimal data collection from the patient medical record, Appl Nurs Res. Author manuscript; available in PMC 2011 Oct 1.