Medical Record Review Conduction Model for Improving Interrater Reliability of Abstracting Medical-Related Information
Medical Record Review Conduction Model for Improving Interrater Reliability of Abstracting Medical-Related Information
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DOI：
10.1177/0163278709338561
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发表时间：
2009-09-01
影响因子：
2.9
通讯作者：
Colantonio, Angela
中科院分区：
文献类型：
--
作者：
Engel, Lisa;Henderson, Courtney;Colantonio, Angela
医疗记录审查（MRR）经常用于临床研究和评估，但关于进行MRR的最佳实践的文献有限，并且很少有研究报告MRR数据的互传信度（IRR）。本研究的目的有两个：(a)开发MRR抽象工具并标准化MRR过程；(b)从MRR数据中检验IRR。本研究引入MRR-传导模型（MRR-传导模型）来实现MRR，并从47名神经损伤工人的医疗记录中收集损伤前医学和精神病学、事件相关医学和伤后头部症状信息，考察两名提取者之间的IRR。结果表明，大多数变量的一致性百分比为>= 85%，未加权kappa统计量为>= 0.60，表明IRR较高。有效可靠的MRR提取医学相关信息需要计划和时间。提出了MRR-传导模型来指导创建MRR的过程。
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 >= 85% and the unweighted kappa statistic was >=.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.