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