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Structured Chart Review: Assessment of a Structured Chart Review Methodology
Ashley Siems1, Russell Banks2, Richard Holubkov2
1School of Medicine and Health Sciences, The George Washington University and Children's National Health System, Washington, District of Columbia.
Hospital Pediatrics
|December 28, 2019
Summary
Structured chart reviews for medical research are reliable and valid. A two-tiered approach using primary and secondary physician reviewers demonstrated high agreement for assessing causes of mortality and morbidity.
Area of Science:
- Medical research methodology
- Clinical data analysis
Background:
- Chart reviews are essential for research, care assessment, and quality improvement.
- Current data on the reliability and validity of chart review methods are lacking.
Purpose of the Study:
- To describe a structured chart review methodology.
- To establish the validity and reliability of this methodology.
Main Methods:
- A 2-tiered review process involving site and central physicians.
- Review of 327 randomly selected cases of mortality or new morbidities.
- Assessment of validity via post-review surveys and reliability via percent agreement and interrater reliability.
Main Results:
- Primary reviewers found information adequate for conclusions in 94.9% of cases.
- High reviewer confidence (94.2%) and ease of conclusion formation (93.2%).
- Excellent agreement for causes (80.5%-100%) and therapeutic advances (68.3%-100%) in duplicate reviews.
Conclusions:
- A structured chart review, particularly with knowledgeable primary reviewers and a secondary review, is both valid and reliable.
- This methodology supports its use in research and quality improvement activities.
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