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Quality of clinical notes for vascular surgery admissions: A CRABEL score review
Author(s) -
Suh Jun,
Roake Justin A.,
Lewis David R.
Publication year - 2009
Publication title -
anz journal of surgery
Language(s) - English
Resource type - Journals
SCImago Journal Rank - 0.426
H-Index - 70
eISSN - 1445-2197
pISSN - 1445-1433
DOI - 10.1111/j.1445-2197.2009.04986.x
Subject(s) - medicine , elective surgery , vascular surgery , test (biology) , emergency medicine , surgery , cardiac surgery , paleontology , biology
Aim: To compare the quality of patient notes between acute and elective admissions in vascular surgery. Method: Patient notes from the 50 most recent acute and elective admissions on a vascular surgical unit were reviewed using the CRABEL score. Points for quality of record keeping were awarded in four categories: Initial Clerking, Subsequent Entries, Consent and Discharge Summary. Total scores were calculated as a percentage. One hundred per cent represents the minimum quality standard expected. Overall CRABEL scores were compared for differences in the quality of note keeping between acute and elective admissions. Further analysis identified areas that need improvement. Results: The mean CRABEL score for acute admissions was 79.2% (77.0–81.3, 95% C.I.) compared to 81.3% (78.8–83.8, 95% C.I.) for elective admissions ( t ‐test P = n.s.). When the individual categories were analysed no statistically significant difference was observed between the two groups for ‘Subsequent Entries’ and ‘Consent’ sections ( t ‐test p = n.s.). ‘Initial Clerking’ category scored significantly better for elective 16.3 out of 20 (15.7–16.9, 95% C.I.) admissions compared to acute admissions 14.6 out of 20 (13.9–15.3, 95% C.I.), ( t ‐test P = 0.00063). ‘Discharge Summary’ section also scored significantly better for elective admissions 9.9 out of 10 (9.9–10.0, 95% C.I.) compared to acute admissions 9.6 out of 10 (9.3–9.9, 95% C.I.), ( t ‐test P = 0.040). Conclusion: There was no statistically significant difference in the overall quality of written patient notes between acute and elective admissions, however ‘Initial Clerking’ and ‘Discharge Summary’ were better documented for elective admissions. Both acute and elective admissions were observed to have substandard quality of record keeping.