Get the free Medical Record Abstraction Form 2011 Surveillance Period Visit Form - cdc

OMB NO: 09200740 EXPIRATION DATE: 05/31/2012 Medical Monitoring Project (MMP) Medical Record Abstraction Form 2011 Surveillance Period Visit Form (SPF) VERSION 7.0.0 OPTIONAL FOR LOCAL USE ONLY MMP

How to fill out medical record abstraction form

1. In order to fill out a medical record abstraction form, you will need to gather all relevant medical records and documents related to the patient. This could include diagnostic reports, treatment records, laboratory results, and any other pertinent information.
2. Start by carefully reading and understanding the instructions provided on the form. Familiarize yourself with the specific sections and data points that need to be abstracted.
3. Begin filling out the form by providing basic patient information such as name, date of birth, gender, and contact details. Ensure that this information is accurate and up-to-date.
4. Move on to the medical history section and carefully document the patient's past medical conditions, surgeries, allergies, and any other relevant information. Be thorough and precise, as this information plays a crucial role in understanding the patient's healthcare needs.
5. Proceed to record the current medical conditions, including details about any ongoing treatments, medications, and care plans. Note down the dates of diagnosis, prescribed medications, and any changes in the treatment plan.
6. The form may also require you to record specific laboratory tests or diagnostic imaging results. Ensure that you provide accurate information about the tests conducted, dates of testing, and the corresponding results.
7. Finally, review the completed form to ensure its accuracy and completeness. Double-check for any missing information or errors that need to be corrected.

Who needs a medical record abstraction form?

1. Healthcare providers: Medical record abstraction forms are essential for healthcare providers to gather relevant patient information quickly and efficiently. They help in making informed decisions about treatment plans, monitoring patient progress, and maintaining comprehensive medical records.
2. Researchers and statisticians: Medical record abstraction forms play a crucial role in research studies and statistical analysis. They provide essential data for analyzing trends, identifying patterns, and conducting population-based studies.
3. Insurance companies: Insurance companies often require medical record abstraction forms to assess the validity of claims, determine coverage, and understand the medical history of the insured individual.
4. Legal professionals: Lawyers and legal professionals may need medical record abstraction forms to gather evidence related to a medical malpractice case or personal injury claim.
5. Government agencies: Government agencies, such as those involved in public health or healthcare policy, may use medical record abstraction forms to gather population-level data and make informed decisions regarding public health initiatives.

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What is medical record abstraction form?

Medical record abstraction form is a document used to extract relevant information from a patient's medical records for analysis or reporting purposes.

Who is required to file medical record abstraction form?

Healthcare providers, researchers, or organizations may be required to file medical record abstraction forms.

How to fill out medical record abstraction form?

The medical record abstraction form is typically filled out by trained professionals who review the patient's records and extract the necessary information.

What is the purpose of medical record abstraction form?

The purpose of the medical record abstraction form is to gather specific data from the patient's medical history for analysis, research, or reporting purposes.

What information must be reported on medical record abstraction form?

The medical record abstraction form may require information such as patient demographics, diagnosis, treatment, medications, and outcomes.