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

Author(s)

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

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

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

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.

Publication Details

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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