ArticleJournal of pharmacy & bioallied sciences
Assessment of the Quality of Medical Record Documentation using the CRABEL Score Method in a Tertiary Care Hospital in Eastern India.
Article in Journal of pharmacy & bioallied sciences. The graph could read no effect estimate from its abstract, so it casts no vote on the map. Not yet cited in PubMed.
What it found
Each row is one number read from the abstract, on the scale the paper reported it, with its interval. Left of the dashed line favours the treatment, right favours the comparator. Under each row is the sentence it came from. New to these charts? A ten-minute tutorial.
The abstract states no effect estimate the extractor could read, or names no intervention and outcome on the map, so this paper lights no cell and moves no belief. It is still indexed, cited and linked below.
The trial behind it
Trials whose registry record cites this paper, or whose number appears in the abstract. A trial that started after this paper was published is citing it as background, not reporting it.
Neither the registry nor the abstract names a trial number. If this is a trial report, that itself is worth knowing.
Who cites it
0 citing papers in PubMed.
No citing paper in PubMed yet.
Corrections and comments
PubMed lists nothing against this paper. Absence here is not a guarantee, only a check that was made.
Authors and funding
2 authors.
Funding
No grant is acknowledged in the PubMed record.
Abstract
Background: 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. Methodology: 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. Results: 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. Conclusion: 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.
Indexed as
Identifiers
What OpenQuestion holds
Registered trials
Read under generation 80e0d062 · epoch 390. Bibliography from PubMed, PubMed Central and OpenAlex; grants from NIH RePORTER; trial links from ClinicalTrials.gov; estimates, votes and beliefs from the OpenQuestion graph.