quality of surgical case notes using crabel score at Dow university hospital

ABSTRACT

To find out the quality of medical records in the department of surgery at Dow University Hospital, a tertiary care teaching hospital. Medical records of all patients admitted in surgery department of surgery at Dow University Hospital from February 2012 to April 2012 were reviewed. By analyzing two sets of medical notes, a numerical score out of total 100 was calculated which is used as a representative value of quality; 100 being most accurate. For each omission of any of the criteria of CRABEL score, one point was deducted and the total scores was presented as percentage. The overall CRABEL score was 72.1 in all surgical case notes. Most frequents points were deducted in subsequent entry section with total deduction of 30.3% while least deduction was seen in discharge section with total deduction of 4.4%. Quality of Record keeping in surgical department of surgery is 71% in relation to CRABEL score. Subsequent entry section is the major factor in decrease in the quality of notes