How do abstract data from medical records?

Step 1: Gather the necessary information

- Collect the medical records that you want to abstract data from.

- Include the patient's name, medical record number, date of birth, and any other relevant demographic information.

- Collect the dates of service, diagnoses, procedures, medications, and any other relevant clinical information.

Step 2: Understand the abstracting tool to be used

- If the organisation has standardised abstracting tools, familiarise yourself with them; if not, design one suitable for the organisation.

- Abstracting tools usually contain categories and subcategories that guide what data should be captured; ensure you understand these categories and subcategories.

Step 3: Start abstracting

- For each document, carefully review the information and enter it into the appropriate fields of the abstracting tool.

- Be sure to include all of the relevant information required by your abstracting tool.

Step 4: Check your work for accuracy

- Once you have completed abstracting a document, carefully review your work for accuracy. Look for any errors or omissions and correct them as needed.

Step 5: Finalise the abstract

- Once you have checked your work for accuracy, finalise the abstract by signing and dating the document. You may also want to add a brief comment about the content of the abstract.

Step 6: Store the abstract

- Store the completed abstract in a secure location. You may want to consider creating a filing system so that you can easily find abstracts when you need them.