Quality of clinical notes for vascular surgery admissions: a CRABEL score review.
OBJECTIVE
To compare the quality of patient notes between acute and elective admissions in vascular surgery.


METHODS
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).


CONCLUSIONS
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.
Suh
Jun
J
Department of Vascular, Endovascular & Transplant Surgery, Christchurch Hospital & University of Otago, Christchurch School of Medicine, Private Bag 4710, Christchurch, New Zealand.
Roake
Justin A
JA
Lewis
David R
DR
D017558:Elective Surgical Procedures / Q000706:statistics & numerical data; D004630:Emergencies; D006801:Humans; D008485:Medical Audit / Q000379:methods*; D008499:Medical Records / Q000592:standards*; D009520:New Zealand; D010343:Patient Admission / Q000706:statistics & numerical data*; D011786:Quality Control; D013503:Surgery Department, Hospital / Q000592:standards; D014656:Vascular Surgical Procedures