Collecting Health Data with Electronic and Paper Chart Audits

Resource: Collecting Performance Data Using Chart Audits and Electronic Data Extraction (PDF, 2 MB, 5 of 63 (remaining pages are training materials) pages)

Part of an AHRQ curriculum used to train practice facilitators, this resource builds practices’ capacity to access accurate and reliable data from their information systems and to use these data to guide improvement work. In support of Key Driver 3: Optimize health information systems to extract data and support use of evidence in practice, it teaches how to use both paper and electronic systems to assess performance. Although the resource is directed to practice facilitators, it can be used by practices. It includes the following sections:

• Considerations When Collecting Clinical Performance Data.
• Procedures for Paper Chart Audits (including sample abstraction form).
• Procedures for Electronic Health Record Audits.
• Balancing Capacity Building and Hands-On Support in Getting Data.
• Privacy and Data Security.

Institution of origin: Agency for Healthcare Research and Quality

Author(s): Knox L, Brach C, Davis M

Acknowledgements: This document is part of AHRQ’s Primary Care Practice Facilitation Curriculum, available at: https://www.ahrq.gov/ncepcr/tools/transform-qi/deliver-facilitation/curriculum/index.html.

Publication date: September 2015