Medical Record Abstraction Form and Guidelines for Assessing the Appropriateness of Hysterectomy

This report documents the medical record abstraction form and guidelines for appropriateness of hysterectomy used in the HMO Quality of Care Consortium study of this procedure. The abstraction form was designed to follow the format of a medical record so that abstraction would be both accurate and efficient. For each item or group of items, the section of the medical record that was to serve as the source of data was specified. In addition, items derived from a particular portion 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 from the medical record, and provide important medical synonyms. A separate form was developed for use by the physician overreader who was responsible for reviewing the data collected on the abstraction form by the HMO abstractor and reviewed by the nurse supervisor at RAND in order to make necessary clinical judgments. As with the medical records abstraction guidelines, the physician overreader guidelines provide item by item instructions for making the required clinical judgments.