Record Review

Be realistic in the information you expect to derive from a chart or record review.

Sometimes the information you need is already available, but it is not yet entered into a database. Examples might include:

• Details on a prehospital ambulance run report
• Medical examiner records
• A hospital medical chart

It is generally a good idea to set up a data collection form for a chart review so that the data are collected and defined consistently for all of the charts or records you review.

Pay careful attention to how you define the variables and create a detailed data dictionary for each variable you define. Keep in mind that not all data sources are complete, so you may have missing data for several variables. Be realistic in the information you expect to derive from a chart or record review.

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rev. 15-Jul-2006