Structured Chart Review Process in an Abstract

As per an abstract shared by the National Library of Medicine, a chart review is a methodology to determine a retrospective approach and healthcare assessments to conduct quality improvement activities.

However, the reliability and validity of chart review is depending on medical records. The process of chart review can be challenging as it includes unstructured documentation, which demands a structured procedure for review and assessment to resolve discrepancies among multiple chart reviewers for validity and reliability.

The abstract further described mentioned a common-sense multistep approach in accordance with the original Harvard Medical Malpractice Study principles to ensure a standardized structured chart review process.

The initial goal of the structure chart review approach was to define goals and objectives for the chart review process in order to identify pathophysiological (pathology with physiology) processes resulting in new morbidities and mortalities, including therapeutic advances that could reduce morbidity and mortality.

Next, the approach also defined performance parameters to analyze the time taken for reviews. This criterion is considered to ensure that the chart review process is feasible and that the individual behind the chart review process is qualified.

See the steps taken to create the structured chart review process including the examples of the process used in the abstract:

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Image source: National Library of Medicine

The study included eight primary reviewers across seven institutions by third-year individuals and professors. 

The primary reviewers performed 327 reviews and confirmed new morbidity or mortality in 292 cases. The average time for the chart reviews was 30.2 (SD 16.7) minutes per case, as seen in the image below.

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Image source: National Library of Medicine

The secondary reviews by central reviewers along with the primary reviewers took 4.6 (SD 1.9) minutes per case, as seen in the image below.

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Image source: National Library of Medicine

In addition, forty-one reviews underwent 2 independent reviews as described in the image below:

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Image source: National Library of Medicine

Conclusion

The abstract concluded that the case reviews resulted in 30 minutes per case and recommended structured chart review with clear objectives by professional primary reviewers followed by a secondary review to be valid and reliable for quality assessment, research, and chart review process improvement activities.

Reach our expert to adopt an AI-Assisted Chart Review & Audit Solutions.

Click to read the full abstract.

Source

National Library of Medicine

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Disclaimer: All the information, views, and opinions expressed in this blog are inspired by Healthcare IT industry trends, guidelines, and their respective web sources and are aligned with the technology innovation, products, and solutions that RAAPID offers to the Risk adjustment market space in the US.