Medical Record Review Conduction Model for Improving Interrater Reliability of Abstracting Medical-Related Information Academic Article uri icon

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abstract

  • 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.

authors

  • Salerno, Jennifer
  • Engel, Lisa
  • Henderson, Courtney
  • Fergenbaum, Jennifer
  • Colantonio, Angela

publication date

  • September 2009