Understanding Medical Record Abstraction

Abstracting data from medical charts can be a challenging process. But it’s essential to your hospital’s quality score optimization and patient care outcomes.

The medical record abstraction process involves matching information in a chart to data elements required for a study. It includes subjective tasks (categorizing, selecting one value from multiple options, coding, interpreting) and objective tasks (transformation, formatting, calculations).

What is Abstraction?

Abstracting is extracting and entering critical information and data into electronic records. As a healthcare professional, you may need to abstract patient records for many purposes.

Whether it is for medical research, clinical registries, or billing, you need to be able to search for and understand the details necessary for the patient’s care. This requires strong software knowledge and attention to detail.

Abstracting is a vital data management practice in the healthcare industry. It can also help you determine trends in a patient’s diagnostics and care.

What is the Goal of Abstraction?

Technically, medical record abstraction is essential for data gathering and analysis in clinical research, surveillance, illness tracking, quality improvement, performance measurement, cost analysis, and health care reimbursement. It’s also a critical step in migrating to a paperless medical practice.

Despite the importance of this process, abstraction can be tedious and time-consuming. It takes up precious time that could be spent focusing on other aspects of a clinical trial or quality improvement initiative.

To reduce the stress and burden of this task, organizations are now turning to registries that abstract data automatically from patient records for quality measurement purposes. These solutions take away the stress of abstraction and provide accurate, timely data that can be used to improve patient outcomes.

The abstracting process requires that all relevant patient data be entered into pre-defined fields. This includes family history, allergies, immunizations, medications, growth charts, demographics, and other information typically found in paper charts.

What is the Process of Abstraction?

Abstracting medical records is a critical and often complex process. It involves searching for and matching the information in a medical record to the data elements required for secondary use, reporting, or clinical registries.

The abstracting process requires a deep understanding of the medical and electronic healthcare system and keen analytical and project management skills. It also requires working with clinicians to determine what details should be included in the abstraction.

One of the most challenging aspects of this work is accurately and thoroughly completing abstractions within a specific timeline, especially when a health system is going through a go-live. Abstraction service providers with a robust pipeline of abstractors with steady rotation from one project to the next can ensure accuracy and speed in these cases.

Medical record abstraction is a subjective process with a higher cognitive load than other data collection and processing methods. This can make it difficult for a team of abstraction professionals to perform accurately and efficiently.

What is the Importance of Abstraction?

Medical record abstraction is critical to healthcare organizations’ ability to measure and report quality measures and other standards. Data must be gathered quickly, accurately, and thoroughly for these purposes.

To achieve these goals, abstraction service providers must offer speed, accuracy, flexibility, scalability, and visibility in their abstraction solutions. In addition, health plans and other healthcare organizations must budget for these abstraction resources accordingly.

A key component of medical record abstraction is training. Abstractors must receive training before study start-up time and must be able to access the study site.

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