Introduction
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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, surgery reports, and other
clinical and administrative paperwork, are included. This is not an easy task.
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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 data collection tool.
The
utility of patient medical record data in clinical research
At least 25% of scientific publications published in clinical journals use data
from patient medical records obtained through retrospective chart review.
Retrospective medical record review is a valuable tool for exploring complex
research problems to answer using prospective studies.
Collecting patient medical record data for research
Before beginning any medical record
data-gathering project, protocols and 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 for standardising the comprehensive nature of the data collected
Paper
or electronic data collection methods
A paper document or an electronic record can be used to collect data. Both forms of
data-collecting 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
data-collecting makes centralisation and management more effortless.
Conclusion
The medical record has long been
regarded as a valuable data source for clinical
research. When
conducting prospective and retrospective clinical studies that use data from
the medical record, 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.
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