Assessment of the Quality of Medical Record Documentation using the CRABEL Score Method in a Tertiary Care Hospital...

The Medical Record Department plays a crucial role in hospitals, ensuring proper documentation and patient care. The Royal College of Surgeons of England has provided guidelines for auditing medical record documentation, including the CRAwford- BEresford - Lafferty (CRABEL) score. This quick, simple, and valuable method assesses the quality of medical note-keeping, providing a useful image of hospital patient care. The current study analyses the assessment of medical record documentation using the CRABEL score.

The study involved 43,384 patients admitted from 01.01.2022 to 31.12.2022, distributed across 26 specialties and super specialties. A sample size of 400 was assessed using Taro Yamini's formula. A pretested checklist based on the CRABEL Score assessed four sections of medical records: initial clerking, subsequent visits, consent, and discharge/death. MS Excel was used for simple statistical analyses.

Out of 400 case sheets of 26 different departments, the average CRABEL score found was 85.23% ±5.00. The highest being the Dentistry (93.00%) and lowest in Orthopedics (72.83%). The four different area-wise deduction/deficiency scores were, Initial clerking (0.84 ± 0.62), Subsequent visit (13.23 ± 4.97), Consent (0.54 ± 0.58), and Discharge/Death summary (0.04 ± 0.11). The total average deduction/deficiency was 14.64 ± 4.93, highest in Orthopedics and lowest in Dentistry.

Completeness of medical records is essential for proper patient care but is a challenge in most organizations. Based on the deficiencies found in this study further study to mitigate the deficiencies may be proposed e.g., training needs assessment, development of training material, and the impact of training.