THE QUALITY OF SURGICAL CASE NOTES USING CRABEL SCORE AT DOW UNIVERSITY HOSPITAL | [Journal of Postgraduate Medical Institute • 2012]

Author(s):

1. Masood Jawaid: D o w U n i v e r s i t y Hospital and; D o w International Medical College, Dow University of Health Sciences, Karachi - Pakistan

2. Abdul Khalique: Dow University Hospital and Dow International Medical College, Dow University of Health Sciences,Karachi,Pakistan

3. Foad Ali Moosa: Dow University Hospital and Dow International Medical College, Dow University of Health Sciences,Karachi ,Pakistan

4. Nighat Bakhtiar: Dow University of Health Sciences, Karachi Pakistan

Abstract:

: To find out the quality of medical records in the department of surgery at Dow University Hospital, a tertiary care teaching hospital. Methodology: 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. Results: 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%. Conclusion: 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.

Page(s): 412-417

DOI: DOI not available

Published: Journal: Journal of Postgraduate Medical Institute, Volume: 26, Issue: 4, Year: 2012

Keywords:

Quality , Audit , CRABEL , Medical records

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