Medical record review, also known as retrospective chart review, is a study type in which researchers do not collect new data but instead rely on patient-centred information that was already collected. This data may come from a variety of sources, such as databases of health providers and information published by the Department of Health (Vassar & Holzmann, 2013). The most significant mistake researchers make when conducting a retrospective chart review is the failure to formulate a clear research question (Gearing et al., 2006). Data collection is also a challenge – researchers should know what data to collect and this choice is determined by what variables are measured in the study. The way information is obtained is influenced by the institution where the study is being conducted (Children’s Healthcare of Atlanta, 2019). That is because the institution may have specific limitations on what data can be extracted and how it may be used. It is possible to access the databases only after approval from an institutional review board.
Researchers cannot control the reliability of the data because it was not collected by them. Therefore, retrospective chart reviews should be conducted using information only from credible institutions. However, the validity is determined in the context of information’s relevance to the topic of study (Vassar & Holzmann, 2013). The first step when attaining records from a database is checking the documentation process to see whether a record can be considered reliable (Gearing et al., 2006). The second step is to determine what abstractor will be used in the study (Vassar & Holzmann, 2013). Finally, medical records are abstracted – for this step, meeting with coding professionals may be necessary.
Children’s Healthcare of Atlanta. (2019). Retrospective and prospective chart review guidance. Web.
Gearing, R. E., Mian, I. A., Barber, J., & Ickowicz, A. (2006). A methodology for conducting retrospective chart review research in child and adolescent psychiatry. Journal of the Canadian Academy of Child and Adolescent Psychiatry, 15(3), 126-134.
Vassar, M., & Holzmann, M. (2013). The retrospective chart review: Important methodological considerations. Journal of Educational Evaluation for Health Professions, 10(12), 1-7.