Medical record review conduction model for improving interrater reliability of abstracting medical-related information.
Medical record review (MRR) is often used in clinical research and evaluation, yet there is limited literature regarding best practices in conducting a MRR, and there are few studies reporting interrater reliability (IRR) from MRR data. The aim of this research was twofold: (a) to develop a MRR abstraction tool and standardize the MRR process and (b) to examine the IRR from MRR data. This study introduces the MRR-Conduction Model, which was used to implement a MRR, and examines the IRR between two abstractors who collected preinjury medical and psychiatric, incident-related medical and postinjury head symptom information from the medical records of 47 neurologically injured workers. Results showed that the percentage agreement was > or =85% and the unweighted kappa statistic was > or =.60 for most variables, indicating substantial IRR. An effective and reliable MRR to abstract medical-related information requires planning and time. The MRR-Conduction Model is proposed to guide the process of creating a MRR.
Engel
Lisa
L
University of Toronto, ON, Canada.
Henderson
Courtney
C
Fergenbaum
Jennifer
J
Colantonio
Angela
A
D000043:Abstracting and Indexing / Q000592:standards; D005568:Forms and Records Control; D006302:Health Services Research / Q000379:methods*; D006801:Humans; D008485:Medical Audit / Q000379:methods*; D008499:Medical Records; D015588:Observer Variation; D015203:Reproducibility of Results