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The Diabetes Educator

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Evaluation & the Health Professions
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Reviews

Medical Record Review Conduction Model for Improving Interrater Reliability of Abstracting Medical-Related Information

Lisa Engel

University of Toronto

Courtney Henderson

University of Toronto

Jennifer Fergenbaum

Toronto Rehabilitation Institute University of Toronto

Angela Colantonio

Toronto Rehabilitation Institute University of Toronto, angela.colantonio{at}utoronto.ca

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.

Key Words: medical record review • retrospective • methodology • data abstraction • interrater reliability • MRR-Conduction Model

This version was published on September 1, 2009

Evaluation & the Health Professions, Vol. 32, No. 3, 281-298 (2009)
DOI: 10.1177/0163278709338561
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