Training as an Intervention to Decrease Medical Record Abstraction Errors Multicenter Studies.
Stud Health Technol Inform
; 257: 526-539, 2019.
Article
en En
| MEDLINE
| ID: mdl-30741251
Studies often rely on medical record abstraction as a major source of data. However, data quality from medical record abstraction has long been questioned. Electronic Health Records (EHRs) potentially add variability to the abstraction process due to the complexity of navigating and locating study data within these systems. We report training for and initial quality assessment of medical record abstraction for a clinical study conducted by the IDeA States Pediatric Clinical Trials Network (ISPCTN) and the Eunice Kennedy Shriver National Institute of Child Health and Human Development (NICHD) Neonatal Research Network (NRN) using medical record abstraction as the primary data source. As part of overall quality assurance, study-specific training for medical record abstractors was developed and deployed during study start-up. The training consisted of a didactic session with an example case abstraction and an independent abstraction of two standardized cases. Sixty-nine site abstractors from thirty sites were trained. The training was designed to achieve an error rate for each abstractor of no greater than 4.93% with a mean of 2.53%, at study initiation. Twenty-three percent of the trainees exceeded the acceptance limit on one or both of the training test cases, supporting the need for such training. We describe lessons learned in the design and operationalization of the study-specific, medical record abstraction training program.
Palabras clave
Texto completo:
1
Colección:
01-internacional
Base de datos:
MEDLINE
Asunto principal:
Registros Médicos
/
Errores Médicos
Tipo de estudio:
Clinical_trials
Límite:
Child
/
Humans
Idioma:
En
Revista:
Stud Health Technol Inform
Asunto de la revista:
INFORMATICA MEDICA
/
PESQUISA EM SERVICOS DE SAUDE
Año:
2019
Tipo del documento:
Article
Pais de publicación:
Países Bajos