Research Methodologies that result in adequate data Collecting from the patient Medical Record An Academic presentation by Dr. Nancy Agnes, Head, Technical Operations, Pubrica Group: www.pubrica.com Email: sales@pubrica.com
TODAY'S DISCUSSION Outline In brief Introduction Strategies for conducting medical record review in clinical nursing research Conclusion About Pubrica
IN BRIEF Clinical research frequently
led by nurse investigators
includes
data
gathered
from
the
patient medical record.
The
rigour
of
procedures dependability
the
is
Health
related and,
data to
ultimately,
collection
the the
data's study's
analytical output.
Contd...
Developing instrument, and
a
implementing
continual
personnel
precise
are
data a
coding
communication all
tactics
collection
with for
accurate patient medical records.
manual, research
collecting
INTRODUCTION Nurses undertaking clinical research usually use the patient medical record as a valuable data source.
The patient
medical record
is frequently used
as a primary source of retrospective data for epidemiological analysis.
It
is
widely
observed
as
the
gold
standard
in
any
study
designed
to
determine
demographic factors, clinical data variables, specific aspects of treatment regimens, and, ultimately, patient mortality and morbidity.
Reviewing
particular
sources
within
the
medical record
is
required
for
data
collection and analysis help. Nursing, physician, and consultation notes, as well as admission
and
discharge
reports,
laboratory
and
diagnostic
test
results,
reports, and other clinical and administrative paperwork, are included.
This is not an easy task.
surgery
Before beginning the data gathering endeavour, you must have a solid plan in place. This article describes tactics that may be used to guarantee that data from the medical record is collected as efficiently as possible.
Both retrospective and prospective data gathering efforts have effectively proved the effectiveness of these research methodologies.
The
recommended
techniques
would
equip
nurse
investigators
with
particular
approaches to help research staff collect patient medical records using a
collection tool.
data
THE UTILITY OF PATIENT MEDICAL RECORD DATA IN CLINICAL RESEARCH At
least
published patient
25% in
of
clinical
medical
scientific journals
records
publications
use
data
obtained
from
through
retrospective chart review.
Retrospective medical record
review
is
a
valuable tool for exploring complex research problems to answer using prospective studies.
The study of potentially deleterious consequences of exposures and unusual occurrences in exposures when randomisation is impossible are examples of these questions.
A
medical record review
is a helpful tool for examining problems in
perinatal research because of the ethical considerations connected with research involving vulnerable individuals.
COLLECTING PATIENT MEDICAL RECORD DATA FOR RESEARCH Before
beginning
gathering
project,
any
medical
protocols
record
and
data-
criteria
for
data abstraction from the medical record must be devised.
The
development
and
testing
of
a
data
collection tool; the use of a coding manual guiding health data collection support services of specific variables from the medical record.
And (c) the selection, training, management, and ongoing communication with research staff are all strategies that underpin these protocols and guidelines (i.e., data abstractors)
the
Research methodologies given to address these three critical aspects
of data abstraction from the medical record.
DETAILED NATURE OF THE DATA TO BE COLLECTED FROM THE MEDICAL RECORD Variables
should
be
reported
on
the
data
collection instrument with a short, unequivocal response to ensure validity and accuracy of data gathering.
A categorical response may be assigned when numerical data is unavailable or acceptable for a particular research variable.
These replies can record surgical or radiological results and absent or unknown factors. For the research team gathering data from the medical record,
the
categories
must
be
established
on
the
data
collection
instrument.
The internal validity and reproducibility of any retrospective study are dependent
on
these
strategies
nature of the data collected.
for
standardising
the
comprehensive
PAPER OR ELECTRONIC DATA COLLECTION METHODS A paper document or an electronic record can be used to collect data. Both forms of datacollecting technologies have their own set of advantages and disadvantages.
At the point of data collection, which is often in
the
medical
records
department
across
numerous sites, a paper document is frequently more cost-effective and easier to use.
The usage of a paper document, on the other hand, necessitates the data being put into an electronic database for analysis.
Even
under
ideal
conditions,
the
data
input
procedure
is
rife
with
the
potential for human error, which can distort analysis and research results.
Electronic data collecting straight into a database reduces the possibility of data input errors, resulting in more trustworthy image data collection support and analysis
Furthermore,
computerised
management more effortless.
data-collecting
makes
centralisation
and
STRATEGIES FOR CONDUCTING MEDICAL RECORD REVIEW IN CLINICAL NURSING RESEARCH
Data management becomes
more
is
critical
challenging
to
during
any
maintain
research
while
project.
performing
Data
studies
management
involving
many
variables acquired from the medical record across different study locations.
The
following
attributes
may
be
included
in
the
data
management
protocol:
scheduled research team meetings with all data abstractors and the study's principal investigator (PI) or project director (PD); regular, ongoing communication with the study's PI and PD to resolve questions and data conflicts
And the formation of an independent committee or panel of experts to serve as consultants to the data abstractors when conflicts arise.
CONCLUSION The
medical record
has long been regarded
as a valuable data source for clinical research. When
conducting
retrospective from
the
clinical
medical
prospective studies
record,
that
and
use
data
investigators
must
adopt 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 creation and testing of a data collecting instrument, the use of a coding manual to guide multilingual data collection of specific variables from the medical record, and the selection, training, and management of a research team of data abstractors are all strategies mentioned in this article.
ABOUT PUBRICA At Pubrica, we collect data from various sources and perform semantic annotation based on the research questions you want to solve. The vast majority of the data in doctor's notes are available on Pubrica; electronic medical records, medications, and other related data are also public.
Although this is where big data's golden opportunity in medical care resides, it's challenging to yield valuable insights due to complex, unstructured, longitudinal, and voluminous data.
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