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Case Abstraction

Case Abstraction Wheel

Note: Information in this section is adapted from the comprehensive Abstractor Manual developed by the MMRIA project, a partnership with Review to Action. For more detailed information, please download the manual from the recommended resources below.

Case abstractors are the most critical members of MMRCs. Their expertise and skill as medical record abstractors are directly tied to the quality of information that is presented to the MMRC and ultimately to the accuracy of identified issues and recommendations for improvement. Case abstraction is most successful when maternal death case abstractors are nurses with five or more years of experience in obstetric care. Case abstractors must have a basic understanding of the significance of changes in vital signs, reported symptoms, and subsequent events, as well as documentation of escalation of care.

Case abstractors typically receive cases from the administrative coordinator of the review and abstract cases within a specified time. They are responsible for reviewing records at each hospital, filling out appropriate abstraction forms, writing a case narrative and providing additional information on each case based on clinical documentation in the records. While most records are found at area hospitals, some cases abstractors may be required to gather information from other types of facilities. In certain instances, case abstractors are solely responsible for contacting hospitals and arranging access to medical records for assigned cases. In other cases, administrative coordinators share the responsibility as well.

Sources of information for abstraction

Due to differences in the statutes and authorities across states and jurisdictions under which an MMRC operates, the places where information may be gathered may be restricted. Barring any legislative limitations, case abstractors can gather information from as many of the following sources as possible and feasible:

  1. Vital statistics (death certificates, birth certificates, fetal death records)
  2. Prenatal records
  3. Hospital records (outpatient and inpatient stays)
  4. Outpatient clinic records: these records may be from preconception/family planning clinics, or primary care centers
  5. Autopsy reports and case findings from hospital, coroner, or other medical examiner
  6. Police/investigative reports
  7. Medical transport records
  8. Personal interviews of providers, family, or friends

After case abstraction is complete, the case needs to be summarized. MMRCs are encouraged to use a standard case narrative template to promote a standardized format for reviewing cases. The narrative succinctly captures all relevant medical information and presents the events leading to the woman’s death in chronological order. The case narrative supplements, but does not replace, the full set of data abstracted by the case abstractor.

MMRIA MMRC Abstractor Manual

Year of publication or last update: 

This manual is an in-depth guide to case abstraction, intended for abstractors both seasoned and new to their positions.