Abstraction 101

Lynne HallBest Practice PowerHour

February 2013

Outline

I. Brief OverviewII. Materials NeededIII. How to beginIV. AbstractingV. ReviewVI. Questions

Brief Overview

What is Abstraction? According to dictionary.com

Brief Overview 2

• For our purposes we will use the following definition!

– The collection of information from the medical record via hardcopy or electronic copy for data collection purposes.

Brief Overview 3

• Abstracting charts is not easy – but you are not alone AND it does get easier!!

• You need to always keep up with the most recent “Specifications” Manual– This is your resource for everything related to

abstraction– Use Quality Net Quest to answer questions

you may have along the way– Use Quality Net training on the following page

Brief Overview 4

These are Mock charts with answer keys. It is another way to help you to learn abstraction.

Materials Needed

In order to abstract charts well you will need the following:

1. A list of all charts to be abstracted from each of the measure sets your hospital has chosena. You need to have medical records pull those

charts for you to begin abstracting; or if you have electronic records, then you need access to all information regarding the patients (labs, radiology, etc)

Materials Needed 2

In order to abstract charts well you will need the following:

2. The Specifications Manual for the quarter that you are abstracting a. Pull up the Alpha Data Dictionary from

www.qualitynet.org or from http://www.jointcommission.org/PerformanceMeasurement/PerformanceMeasurement/

3. The abstraction tool for each measure set (you can either use the paper tool or abstract directly into CART)

Specifications manual

How to Begin• Make sure you have all your materials• Open CART if you plan on abstracting

directly into CART – if not, make sure you have enough paper copies of the tools you need for the measure set you are abstracting

• The first thing to do is check to make sure any preformatted information is correct; i.e.: name, DOB, Medicare HIC#, etc

How to Begin 2• It’s as simple as starting at question one!

– It is important to know which parts of the chart have a priority order

– Make sure you understand the inclusions and exclusion for each question

– Look up any question in data dictionary if there is doubt on how you should answer it

– NEVER ASSUME when abstracting!!

Let’s look at HF Abstraction

Abstracting

Abstracting 2

Abstracting 3

How to Begin 32

How to Begin 4

How to Begin 5

Review• At some point, if you are new to

abstracting, you need to read all the data dictionary that pertains to the core measures you are abstracting

• Also make sure you are abstracting from the correct version of the Specifications Manual each quarter

• Never ASSUME

Review 2

• Use the data dictionary often!• Whenever possible DO NOT use UTD (Unable

to determine)– This can possibly make your scores lower as CMS

and Joint Commission advocate correct charting• Ask Questions if you are unsure or have

conflicting information– Either of another colleague who abstracts, a peer at

another hospital, Qnet Quest, or you can always email Lynne Hall ( lhall@gha.org ) or Diana Smith from GMCF

Questions