• Nurses undertaking clinical research usually use the patient medical record as a valuable data source. The patient medical record is frequently used as a primary source of retrospective data for epidemiological analysis. It is widely observed as the gold standard in any study designed to determine demographic factors, clinical data variables, specific aspects of treatment regimens, and, ultimately, patient mortality and morbidity. Reviewing particular sources within the medical record is required for data collection and analysis help. Nursing, physician, and consultation notes, as well as admission and discharge reports, laboratory and diagnostic test results, surgery reports, and other clinical and administrative paperwork, are included. This is not an easy task.
  • Before beginning the data gathering endeavour, you must have a solid plan in place. This article describes tactics that may be used to guarantee that data from the medical record is collected as efficiently as possible. Both retrospective and prospective data gathering efforts have effectively proved the effectiveness of these research methodologies. The recommended techniques would equip nurse investigators with particular approaches to help research staff collect patient medical records using a data collection tool.


The utility of patient medical record data in clinical research

At least 25% of scientific publications published in clinical journals use data from patient medical records obtained through retrospective chart review. Retrospective medical record review is a valuable tool for exploring complex research problems to answer using prospective studies.


Collecting patient medical record data for research

Before beginning any medical record data-gathering project, protocols and criteria for data abstraction from the medical record must be devised. The development and testing of a data collection tool; the use of a coding manual guiding health data collection support services of specific variables from the medical record; and (c) the selection, training, management, and ongoing communication with research staff are all strategies that underpin these protocols and guidelines (i.e., data abstractors)—the research methodologies given to address these three critical aspects of data abstraction from the medical record.


Detailed nature of the data to be collected from the medical record

Variables should be reported on the data collection instrument with a short, unequivocal response to ensure validity and accuracy of data gathering. A categorical response may be assigned when numerical data is unavailable or acceptable for a particular research variable. These replies can record surgical or radiological results and absent or unknown factors. For the research team gathering data from the medical record, the categories must be established on the data collection instrument. The internal validity and reproducibility of any retrospective study are dependent on these strategies for standardising the comprehensive nature of the data collected


Paper or electronic data collection methods

A paper document or an electronic record can be used to collect data. Both forms of data-collecting technologies have their own set of advantages and disadvantages. At the point of data collection, which is often in the medical records department across numerous sites, a paper document is frequently more cost-effective and easier to use. The usage of a paper document, on the other hand, necessitates the data being put into an electronic database for analysis. Even under ideal conditions, the data input procedure is rife with the potential for human error, which can distort analysis and research results. Electronic data collecting straight into a database reduces the possibility of data input errors, resulting in more trustworthy image data collection support and analysis. Furthermore, computerised data-collecting makes centralisation and management more effortless.



The medical record has long been regarded as a valuable data source for clinical research. When conducting prospective and retrospective clinical studies that use data from the medical record, investigators must adopt a strategic approach to data gathering activities and use a rigorous methodology. A deliberate strategy to conduct retrospective chart reviews in clinical nursing research will generate high-quality data and reliable outcomes.


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