Data Abstraction Training Resources

Mock medical records (fictitious charts) have been developed for use by hospitals and Medicare Quality Improvement Organizations (QIOs) in training data abstractors. Staff can use the gold standard records listed below to practice abstracting data for submission to the QIO Clinical Warehouse. Three charts are provided for each clinical topic.

Abstractions of the mock medical records for each topic are provided as “answer keys.” These abstracted cases were created using paper tools (which utilize the Suggested Data Collection Questions from the Specifications Manual for National Hospital Inpatient Quality Measures). The abstracted cases correlate with the CMS and Joint Commission abstraction guidelines for discharges from 04-01-10 through 09-30-10.

Acute Myocardial Infarction (AMI)

Heart Failure (HF)

Pneumonia (PN)

Surgical Care Improvement Project (SCIP)

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