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This Report documents the medical record abstraction form and guidelines used to collect data on the quality of prenatal care for the HMO Quality of Care Consortium project. The abstraction form was designed to be consistent with the format of a medical record to enhance the accuracy and efficiency of the abstraction process. Within each set of related items, the specific source of data in the medical record was specified. For example, both progress notes and laboratory reports are used as sources of information about tests that were done during the prenatal care period. In addition, items derived from a particular part of the medical record were grouped. To standardize the abstraction process, a detailed set of guidelines was prepared to accompany the abstraction form. The guidelines define medical terms, specify data sources to be used in obtaining information from the medical record, and provide important medical synonyms. Each item in the abstraction form has a corresponding section in the guidelines.

Prenatal care --- Medical records --- Prenatal Care --- Quality Assurance, Health Care --- Evaluation --- Forms. --- Abstracting and indexing. --- standards.

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Behavioral health (BH) conditions—such as posttraumatic stress disorder, depression, and anxiety—are the second most common medical reasons for nondeployability in the U.S. Army. The authors of this report aimed to identify promising metrics to assess readiness among soldiers and adult family members who receive BH care. These metrics would expand the Army's outcome monitoring, which currently includes symptom improvement metrics, for patients who received BH care. The authors developed rigorous criteria to evaluate candidate readiness metrics, conducted interviews with stakeholders (Army subject-matter experts and BH providers), reviewed existing sources of data that could support the development of a readiness metric, and conducted a literature review to identify instruments that have been used to measure readiness-related domains in both military and civilian populations. The authors found that no existing data source or patient self-report instrument met criteria for implementation of a readiness metric for soldiers, but one instrument, the Walter Reed Functional Impairment Scale (WRFIS), is promising. No existing data source or patient self-report instrument met criteria for Army-wide implementation of a readiness metric for adult family members. Stakeholders reported that psychiatric symptoms, diagnosis, treatment, and impaired functioning are important indicators of lack of readiness among soldiers and adult family members. BH providers reported variability in assessing readiness and applying profiles, but behavioral experts provided suggestions for improving readiness assessment. The authors recommend that the Army conduct a pilot evaluation of a soldier readiness metric based on the WRFIS and increase standardization in applying profiles by continuing provider training.

Families of military personnel --- Soldiers --- Services for --- Evaluation. --- Mental health --- United States