Module 6: Case Report Form (Chart Abstraction)

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Presentation transcript:

Module 6: Case Report Form (Chart Abstraction)

This training session contains information regarding: Overview the CRF

At this point you have done the following: Identified Eligible Respondents Obtained Consent Enrolled Respondents Administered the ACP Questionnaire Next… you will need to collect data from the medical record into the Case Report Form Completion (i.e. Chart Abstraction)

Identifying Respondents In order for the site to be able to access the relevant medical record, they will need to know the unique, hospital assigned, medical record number. We recommend keeping an identification list. You can find a template on the study website.

What is a CRF? Data abstracted from medical charts Official clinical data collection document Data abstracted from medical charts Allows for efficient and complete data processing, analysis and reporting Study questions determine what data should be collected on the CRF

Tips for Completing Chart Abstraction Understand what data you are looking for Orient yourself to the various sections of your local medical charts Paper Electronic Determine any local standards used to document ACP/AD Sometimes there are several sources for the same information. The best thing to do is be consistent.

Documentation of ACP/AD in Medical Chart The purpose of this section is to record any ACP/AD documents found on the medical record at the time the questionnaire is completed. If both the patient and family member participate, section 5 should be completed at the point of first contact. (i.e. after the first questionnaire is completed).

If blank documents are found in the medical chart (e. g If blank documents are found in the medical chart (e.g. goals of care form, tracking record or My Voice workbook) leave the corresponding row blank.

Comorbidities Patient characteristics that affect outcomes Medical Chart sources of info: Admission notes, ED assessments, previous admission notes Progress notes Discharge Summary Collect only those that appear on the CRF, record them by: Body system Illness/condition

Entering Data into REDCap Once you have: Administered the ACP questionnaire(s) Collected the CRF data Degree of system implementation Proceed to enter the data into REDCap. See Module 7 for instructions.

Training Module 6 Complete