Derek Berglund: Conducting a Retrospective Chart Review BACK

Published by Gwen Cullen

I am now near the midpoint of my retrospective chart review as part of the MSTAR program and the project has been an even greater learning tool than I originally anticipated. I have been looking at medical records for quite some time now and thus the daily process of reviewing them has become fairly automatic. However, I am still intrigued by the information I find while reading through cases. After looking through many records, I have begun to pick up on trends even before performing statistical analysis. For example, in my study on elderly patients undergoing surgery for hip fracture, I have noticed that a large number of these patients are discharged to nursing homes even if they originally lived at home, were independent, and had good health. I also enjoy reading through the clinical resumes on how the hip fracture injuries occur and what each patient’s hospital course consists of. I have encountered a range of different scenarios with some stories being simple and some absurd. This variety keeps my work interesting and my brain engaged.

I begin a typical day by biking to the hospital and taking the elevator to the floor where the medical records office is located. I head to the physician’s lounge where most of my work is done. The room contains computers but I usually prefer an empty desk so I may use my own laptop. I then locate and collect the charts I wish to review. I normally review about twenty-five charts per day but there are usually only about fifteen of these that meet the inclusion criteria for my study. Records from 2009 to the present are found through the online system and thus are easy to access. Records older the 2009 must be obtained in hard copy form and I order these from the medical records office several days before I plan to review them. I take each box back to the physician’s lounge and go through them one by one. One problem I have encountered when dealing with hard copies is that many records consist of several volumes. Many times, not all of the volumes for a given record are in the same box so I must go through many boxes looking for several parts of one record. Also, hard copies of charts are sometimes incomplete and I therefore cannot acquire all the information I need. For these reasons, it is usually more efficient to review charts in electronic form. At the conclusion of my day, I pack up the boxes with the records and mark the boxes I have finished so that they may be taken back into storage. I then bike back home and start again the following day.

Derek Berglund
Saint Louis University

Diary of an MSTAR Student" follows scholars in the 2012 Medical Student Training in Aging Research (MSTAR) Program, highlighting their summer experiences. As they continue their path of research, training and clinical practice, read their daily thoughts at www.afar.org/mstarblog. New diary entries are posted every day, so check back soon.