Data collection and transcription make up the technical side of clinical abstraction, but the patient is still at the heart of it all. The transition from physical records to mostly digital isn’t just about keeping up with rules and regulations. Every key piece of patient data must be properly moved over into an EHR or a medical CRM system that keeps that data organized and accessible when and wherever necessary, be it in the practice or remotely. Through the abstraction process, clinical data managers are able to move beyond focusing on data alone.
Care providers take in lots of information whenever patients visit the practice or medical facility. As a consequence, much the of the data that gets stored isn’t exactly necessary. Clinical abstraction focuses on a particular framework when dealing with incoming patients; that way, only the most vital pieces of data are kept. Clinical managers may want to concentrate on and ensure data inputs exist for the following categories:
• Family History
• Individual Medical History
• List of Immunizations
• List of Surgical Procedures
• Current and Prior Medications
Each practice is different, however, the aforementioned categories can act as an initial outline for managers just getting started in the world of EMRs or electronic medical records.