THE QUALITY OF SURGICAL CASE NOTES USING CRABEL SCORE AT DOW UNIVERSITY HOSPITAL

Objective: 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.