Abstract
Retrospective chart review is an accessible form of research that is commonly used across medical fields but is underutilized in behavioral health. As a relatively newer area of research, the field of pediatric integrated primary care (IPC) would particularly benefit from guidelines for conducting a methodologically sound chart review study. Here, we use our experiences building a chart review procedure for a pediatric IPC research project to offer strategies for optimizing reliability (consistency), validity (accuracy), and efficiency. We aim to provide guidance for conducting a chart review study in the specific setting of pediatric IPC so that researchers can apply this methodology toward generating research in this field.
This is a preview of subscription content, log in via an institution to check access.
Similar content being viewed by others
Data Availability
Available by request.
Code Availability
Not Applicable.
References
Berry, K. J., Johston, J. E., & Mielke, P. W. (2008). Weighted Kappa for multiple raters. Perceptual and Motor Skills, 107, 837–848.
Cohen, J. (1960). A coefficient of agreement for nominal scales. Educational and Psychological Measurement, 20(1), 37–46.
Coleman, N., Halas, G., Peeler, W., Casaclang, N., Williamson, T., & Katz, A. (2015). From patient care to research: A validation study examining the factors contributing to data quality in a primary care electronic medical record database. BMC Family Practice, 16, 11. https://doi.org/10.1186/s12875-015-0223-z
Flood, M., & Small, R. (2009). Researching labour and birth events using health information records: Methodological challenges. Midwifery, 25(6), 701–710. https://doi.org/10.1016/j.midw.2007.12.003
Gearing, R. E., Mian, I. A., Barber, J., & Ickowicz, A. (2006). A methodology for conducting retrospective chart review research in child and adolescent psychiatry. Journal of Canadian Academicy of Child and Adolescent Psychiatry, 15(3), 126–134.
Gilbert, E. H., Lowenstein, S. R., Koziol-Mclain, J., Barta, D. C., & Steiner, J. (1996). Chart reviews in emergency medicine research: Where are the methods? Annals of Emergency Medicine, 27, 305–308.
Gregory, K. E., & Radovinsky, L. (2012). Research strategies that result in optimal data collection from the patient medical record. Applied Nursing Research, 25(2), 108–116.
Hoff, A., Hughes-Reid, C., Sood, E., & Lines, M. (2020). Utilization of integrated and colocated behavioral health models in pediatric primary care. Clinical Pediatrics. https://doi.org/10.1177/0009922820942157
Zozus, M. N., Pieper, C., Johnson, C. M., Johnson, T. R., Franklin, A., Smith, J., & Zhang, J. (2015). Factors affecting accuracy of data abstracted from medical records. PLoS One, 10(10), e0138649. https://doi.org/10.1371/journal.pone.0138649
Hoffses, K.W., Ramirez, L.Y., Berdan, L., Tunick, R., Honaker, S.M., Meadows, T.J., Shaffer, L., Robins, P.M., Sturm, L., Stancin, T. (2016). Topical review: Building dompetency: Professional skills for pediatric psychologists in integrated primary care settings. Journal of Pediatric Psychology, 41(10), 1144–1160. https://doi.org/10.1093/jpepsy/jsw066
Liddy, C., Wiens, M., & Hogg, W. (2011). Methods to achieve high interrater reliability in data collection from primary care medical records. Annals of Family Medicine, 9(1), 57–62. https://doi.org/10.1370/afm.1195
Lines, M. M. (2019). Advancing the evidence for integrated pediatric primary care psychology: A call to action. Clinical Practice in Pediatric Psychology, 7(2), 179–182. https://doi.org/10.1037/cpp0000283
Lowenstein, S. R. (2005). Medical record reviews in emergency medicine: The blessing and the curse. Annals of Emergency Medicine, 45, 452–455.
McHugh, M. L. (2012). Interrater reliability: The Kappa statistic. Biochemia Medica, 22(3), 276–282.
Panacek, E. A. (2007). Performing chart review studies. Air Medical Journal, 26(5), 206–210.
Talmi, A., Muther, E. F., Margolis, K., Buchholz, M., Asherin, R., & Bunik, M. (2016). The scope of behavioral health integration in a pediatric primary care setting. Journal of Pediatric Psychology, 41(10), 1120–1132. https://doi.org/10.1093/jpepsy/jsw065
Tan, W., Hu, J., Zhang, H., Wu, P., & He, H. (2015). Kappa coefficient: A popular measure of rater agreement. Shanghai Archives of Psychiatry, 27(1), 62–67. https://doi.org/10.11919/j.issn.1002-0829.215010
Vassar, M., & Holzmann, M. (2013). The retrospective chart review: Important methodological considerations. Journal of Educational Evaluation for Health Professions, 10, 12.
Worster, A., & Haines, T. (2004). Advanced statistics: Understanding medical record review (MRR) studies. Academic Emergency Medicine, 11(2), 187–192. https://doi.org/10.1197/j.aem.2003.03.002
Yawn, B. P., & Wollan, P. (2005). Interrater reliability: Completing the methods description in medical records review studies. American Journal of Epidemiology, 161(10), 974–977. https://doi.org/10.1093/aje/kwi122
Funding
Not applicable.
Author information
Authors and Affiliations
Contributions
All authors contributed to the study conception and design. Data collection was performed by DH, JD, CF, and FZ. The first draft of the manuscript was written by DH and JD and all authors commented on and edited previous versions of the manuscript. All authors read and approved the final manuscript.
Corresponding author
Ethics declarations
Conflicts of Interest
Danielle R. Hatchimonji, Jennie David, Carmelita Foster, Franssy Zablah, Alexandra Cross-Knorr, Erica Sood, Meghan Lines, and Cheyenne Hughes-Reid declares that they have no conflict of interest.
Ethical Approval
Approved by Nemours IRB.
Consent to Participate
Not applicable.
Consent for Publication
Not applicable.
Human and Animal Rights
Study was approved by Nemours IRB.
Additional information
Publisher's Note
Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.
Rights and permissions
About this article
Cite this article
Hatchimonji, D.R., David, J., Foster, C. et al. Establishing a Valid, Reliable, and Efficient Chart Review Process for Research in Pediatric Integrated Primary Care Psychology. J Clin Psychol Med Settings 29, 538–545 (2022). https://doi.org/10.1007/s10880-022-09881-w
Accepted:
Published:
Issue Date:
DOI: https://doi.org/10.1007/s10880-022-09881-w