Medical Record Abstraction Form and Guidelines for Assessing the Quality of Pre-Natal Care
This Report documents the medical record abstraction form and guidelines used to collect data on the quality of prenatal care for the HMO Quality of Care Consortium project. The abstraction form was designed to be consistent with the format of a medical record to enhance the accuracy and efficiency of the abstraction process. Within each set of related items, the specific source of data in the medical record was specified. For example, both progress notes and laboratory reports are used as sources of information about tests that were done during the prenatal care period. In addition, items derived from a particular part of the medical record were grouped. To standardize the abstraction process, a detailed set of guidelines was prepared to accompany the abstraction form. The guidelines define medical terms, specify data sources to be used in obtaining information from the medical record, and provide important medical synonyms. Each item in the abstraction form has a corresponding section in the guidelines.