This medical records data abstraction example takes one fictional hospital chart of 24 pages, fills a 14-field abstraction form from it, and records the document and page behind every value. It ends with the four values that needed a judgment call and shows how the same chart would be abstracted differently for a registry or an audit.
The sample chart behind this abstraction example
The sample chart is a fictional, 24-page record for one short hospital stay. The patient, the facility, every date and every medication name are invented for this example. No part of it comes from a real person, and the medication names are made up so they cannot be mistaken for real drugs.
The patient is Dana Example, example medical record number EX-100482, example date of birth 1961-07-14. She was seen in the emergency department late one evening, admitted the next day, and discharged four days later. The chart arrived as one scanned PDF, the way many outside records do.
The documents in the chart
| Pages | Document | Author | What it holds |
|---|---|---|---|
| 1 to 2 | Referral letter from an outside clinic | Example clinic physician | Reason for referral, an outside allergy list |
| 3 to 5 | Emergency department note | Example ED physician | Arrival time, triage vitals, allergies, home medications |
| 6 to 9 | Admission history and physical | Example hospitalist | Admitting diagnosis, history, medication list |
| 10 to 17 | Progress notes, one per day | Example hospitalists | Daily plan, medication changes |
| 18 to 21 | Discharge summary | Example hospitalist | Discharge diagnoses, procedures, discharge medications, follow-up |
| 22 | Pharmacy medication reconciliation form | Example pharmacist | Home medications checked with the patient |
| 23 to 24 | Nursing discharge checklist | Example nurse | Discharge time, disposition, education given |
Before abstracting, the pages were split and labelled by document type. A chart that arrives as one long PDF is hard to cite until every page has a document name. Teams that receive charts from other facilities will find more on requesting and sorting outside records in the records retrieval and review category.
The form itself was defined before anyone opened the chart. Defining fields first is step one of the general method in the guide to defining the medical record fields before you start. This example follows that order.
The filled abstraction form for the sample chart
The filled abstraction form below holds 14 fields for the sample chart, each recorded in a fixed format. Dates use year-month-day, times use a 24-hour clock, and medications are written as the chart names them. A value the chart does not contain is recorded as "not documented", never left blank.
The form, filled
| # | Field | Example value |
|---|---|---|
| 1 | Medical record number | EX-100482 |
| 2 | Date of birth | 1961-07-14 |
| 3 | ED arrival date and time | 2026-03-01 23:40 |
| 4 | Inpatient admission date | 2026-03-02 |
| 5 | Discharge date and time | 2026-03-06 14:15 |
| 6 | Admitting diagnosis, as written | "Community-acquired pneumonia" |
| 7 | Principal discharge diagnosis, as written | "Community-acquired pneumonia" |
| 8 | Procedures during the stay | Not documented |
| 9 | Allergies | Corvaxin (hives); no other allergies documented |
| 10 | Admission weight | 72.6 kg |
| 11 | Number of discharge medications | 3 |
| 12 | Discharge medications | Pemtrazol 20 mg tablet daily; Lumaferin 10 mg tablet daily; Velorine 5 mg tablet stopped |
| 13 | Discharge disposition | Home |
| 14 | Follow-up appointment documented | Yes, 2026-03-13 |
Each value is copied, not interpreted. The diagnosis fields hold the words the physician wrote, because deciding what is wrong with a patient is not the abstractor's job. Field 12 records a stopped drug as stopped rather than leaving it off, so a reader can tell "stopped at discharge" apart from "never listed".
Two formatting choices matter for later use. Weight is converted to kilograms with the original value kept in the source column. And "not documented" in field 8 means the abstractor checked every document that could hold a procedure and found none.
The medication fields follow the method in medication list extraction from records, and the allergy field follows allergy list extraction from records. Both go further into status and source rules than this example needs.
Where each abstracted value came from in the chart
Every abstracted value in this example is traced to one document and one page, so a reviewer can open the chart and confirm it in seconds. The source column below is part of the abstraction, not a note added afterwards. A value without a source cannot be checked or defended.
The source map
| # | Field | Example value | Source document | Page |
|---|---|---|---|---|
| 1 | Medical record number | EX-100482 | Every page header | 1 |
| 2 | Date of birth | 1961-07-14 | ED note header | 3 |
| 3 | ED arrival date and time | 2026-03-01 23:40 | ED note, triage block | 3 |
| 4 | Inpatient admission date | 2026-03-02 | Admission history and physical | 6 |
| 5 | Discharge date and time | 2026-03-06 14:15 | Nursing discharge checklist | 23 |
| 6 | Admitting diagnosis | "Community-acquired pneumonia" | Admission history and physical, assessment | 8 |
| 7 | Principal discharge diagnosis | "Community-acquired pneumonia" | Discharge summary, diagnoses | 18 |
| 8 | Procedures | Not documented | Discharge summary, procedures heading reads "None" | 18 |
| 9 | Allergies | Corvaxin (hives) | Referral letter, allergy list | 2 |
| 10 | Admission weight | 72.6 kg (160 lb as written) | ED note, triage vitals | 3 |
| 11 | Number of discharge medications | 3 | Discharge summary, medications | 20 |
| 12 | Discharge medications | See form | Discharge summary, medications | 20 |
| 13 | Discharge disposition | Home | Nursing discharge checklist | 24 |
| 14 | Follow-up appointment | 2026-03-13 | Discharge summary, follow-up | 21 |
Why the page matters as much as the document
A document name alone is not enough in a 24-page chart. The discharge summary in this example covers four pages, and the medication list sits on the third of them. Recording page 20 rather than "discharge summary" saves the reviewer a search and makes disagreements easy to settle.
Dates need the same care. The ED note, the admission note and the discharge summary each carry several dates, and the one at the top of a page is not always the date of the event. The rules for picking the right one are in the guide to which date on a medical record page is the encounter date.
Which values in the abstraction example needed a judgment call?
Four values in this abstraction example needed a judgment call: the arrival time, the allergy list, the stopped medication and the discharge time. In each case the chart held two or more candidate values, and the abstractor chose one by applying a written rule, then recorded which sources disagreed so a reviewer could follow the reasoning.
Arrival time versus admission date
The ED note shows arrival at 23:40 on 2026-03-01, while the admission order is dated 2026-03-02. They are different fields, so both are recorded. The mistake to avoid is using the admission date as the start of the encounter, which would make the stay look shorter than it was.
An allergy that only one document lists
The referral letter on page 2 lists "Corvaxin: hives". The ED note on page 4 reads "NKDA", short for no known drug allergies. The form's rule in this example is to record any allergy documented in any source and to note conflicts. So field 9 holds Corvaxin, with a note that the ED note disagrees. The abstractor does not decide which document is right about the patient; a clinician resolves that.
A medication that was held, then stopped
Progress notes on page 13 say "hold Velorine". The discharge summary on page 20 says "stop Velorine". A held drug and a stopped drug are different statuses. Because the form asks for discharge medications, the discharge summary's "stop" wins and is recorded as stopped.
Two discharge times
The discharge summary is signed at 11:02, and the nursing checklist records the patient leaving at 14:15. The form's definition asks for the time the patient left, so the nursing checklist on page 23 is the source. The signature time is a document time, not an event time.
How the judgment calls were logged
Each judgment call got a one-line note attached to its field, written so a reviewer who never saw the chart could follow it. The note for field 9 in this example reads: "Corvaxin (hives) from referral letter p. 2; ED note p. 4 says NKDA; recorded per rule 'any documented allergy'; conflict flagged." The note for field 5 reads: "Left 14:15 per nursing checklist p. 23; discharge summary signed 11:02 p. 21 is a document time."
Notes like these do three jobs. They let a second abstractor check the reasoning instead of repeating the search. They show a reviewer which rule was applied, so a wrong rule can be fixed once for every chart. And they keep the conflict visible after the form is submitted, so nobody later mistakes a settled field for an obvious one.
Mistakes this example avoids
Three errors are easy to make on a chart like this one. The first is taking the first value found and stopping, which here would have recorded NKDA and missed the referral letter's allergy. The second is dropping a stopped drug, which would have made field 11 read 2 and hidden the change at discharge. The third is citing a document instead of a page, which turns every later check into a search.
What would change in this example for a registry or audit?
The same chart would be abstracted differently for a registry or an audit, because each purpose defines its own fields, sources and rules. A registry wants coded values chosen by its data dictionary. An audit wants proof that values already submitted match the chart. The chart stays the same; the form and the rules change.
For a registry
A registry would replace the free-text diagnosis fields with codes from its own manual and would add fields this example skips, such as a diagnosis date chosen by a priority rule. Its data dictionary, not the abstractor's habit, would decide whether the outside referral letter counts as a source. How registries write and enforce those definitions is covered in clinical registry abstraction.
For an audit
An audit starts from the other end. The auditor already has the submitted values and asks the chart to prove each one. Here the source map above becomes the main evidence. A value whose page cannot be found is treated as unsupported, however likely it seems.
For a billing or records review
A billing review would care about the dates, the disposition and the documented services, and less about the medication details. A records request might need only the discharge summary pages. The purpose decides which of the 14 fields matter.
For a research study
A study would add its own fields and its own exclusions, and it would usually ask for a de-identified copy of the form. The medical record number and date of birth in fields 1 and 2 would be replaced by a study ID kept in a separate linking file. The source map would still be kept, because anyone checking the study data later will want to trace each value back to its page.
Whatever the purpose, the habit that makes the work reusable is the same: one value, one source page, one note for every judgment call. Schema Care applies that habit to medical records by returning each field with a link to its place on the page, along with a confidence score; the record fields it reads are listed under documents Schema Care reads.