Medical Record Data Abstraction

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Medical Record Data Abstraction
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Section Overview

• Type of information needed from medical record
  during an emergency
• Where to find specific information in a medical
  chart
• Example of hospital chart
• Example of a data collection form

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Information needed from medical record during an
emergency

• Contact information Name, address, telephone
  number
• Demographic information - date of birth, sex,
  race/ethnicity
• Symptoms - Describe how the patient feels
• Physical examination/ signs
• Facts about how the patient looks
• Includes measures like temperature, blood
  pressure, weight
• Laboratory information
• Disposition

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Where to find specific information in a medical
chart

• Demographics, alternate contact, and chief
  complaint
• History and physical
• Symptoms and physical exam
• Lab results
• Consultant notes
• Disposition and treatment plan
• Discharge summary

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Emergency department registration form
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Patient demographic/contact information
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Patient alternate contact (next of kin) follows
demographic information
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Chief complaintand date/time of onset
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Doctor / nurse note C.C. (chief complaint),
describes symptoms
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Doctor / nurse note physical exam section
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Lab abbreviations
CBC
hemoglobin
White blood cell count
platelets
hematocrit
Chemistry
chloride
sodium
blood urea nitrogen
creatinine
bicarbonate
potassium
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Diagnosis / Assessment, Treatment/ Plan, ICD Codes
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Discharge Disposition
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Example of a data collection form

• Simple forms for standard data collection
• Forms may change as the epidemiologists learn
  more about the illness / event
• Forms will be modeled for the situation
• Hospital medical record review of individual
  patient
• List of symptoms for the collection of multiple
  patients with the same illness

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Data collection form - foodborne outbreaks
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Data collection form - foodborne outbreaks
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A computerized record demographics and chief
complaint
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Data collection form - foodborne outbreaks
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A computerized record history physical
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Data collection form - foodborne outbreaks
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Physician assessment
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Treatment plan/ Disposition
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Diagnosis / disposition
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Final Tips For Data Collection During Emergency

• Fill out every item on the form you are given
• If you cannot find an answer, write or circle
  dont know
• Write clearly
• Make sure numbers are easy to interpret
• Information not asked for on form
• Enter in margin
• Only if appears to be directly relevant

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Accessing charts

• Introduce yourself and show your ID
• Always be cordial
• Medical providers may not have time to help you
• Stay calm if access is a problem
• Alert your supervisor to any problems