Quality of clinical notes for vascular surgery admissions: a CRABEL score review

Area of Science:

• Medical record quality assessment
• Vascular surgery patient documentation

Background:

• High-quality patient notes are crucial for effective medical care and patient safety.
• Previous research has not extensively compared documentation quality between acute and elective surgical admissions.

Purpose of the Study:

• To evaluate and compare the quality of patient record-keeping between acute and elective admissions in a vascular surgery setting.
• To identify specific areas within patient notes that require improvement for both admission types.

Main Methods:

• A retrospective review of patient notes from 50 acute and 50 elective vascular surgery admissions was conducted.
• The CRABEL score was utilized to assess the quality of record-keeping across four categories: Initial Clerking, Subsequent Entries, Consent, and Discharge Summary.
• Scores were calculated as percentages, with 100% representing the minimum expected standard.

Main Results:

• Overall CRABEL scores showed no statistically significant difference between acute (79.2%) and elective (81.3%) admissions.
• Elective admissions demonstrated significantly better scores in 'Initial Clerking' (P=0.00063) and 'Discharge Summary' (P=0.040) compared to acute admissions.
• No significant differences were found in 'Subsequent Entries' and 'Consent' sections between the two groups.

Conclusions:

• While overall patient note quality did not differ significantly, elective admissions had superior documentation in initial clerking and discharge summaries.
• Both acute and elective admissions exhibited substandard record-keeping quality, highlighting a need for enhanced documentation practices.
• Targeted improvements in initial clerking and discharge summaries are recommended for vascular surgery patient notes.