Use of the CRABEL Score for improving surgical case-note quality

CRABEL Score Assessment for Oral Surgery Excision Biopsy Case Notes of Oral Squamous Cell Carcinoma

Background Oral surgical records contain all the information regarding a patient, including their history, clinical findings, diagnostic test results, pre-and postoperative care, progress, and medication. Notes that are properly drafted will help the physician argue that the course of therapy is appropriate. Several tools have been created for auditing clinical records; one such tool that may be used for any inpatient specialty is the CRABEL score system developed by CRAwford-BEresford-Lafferty. Aims This research aimed to evaluate the oral surgical records using the CRABEL scoring system for quality assessment. Materials and methods The case audit was performed from June 2023 to February 2024 for all Excisional biopsy cases of Oral Squamous Cell Carcinoma. Relevant data was retrieved from the Dental Information Archival Software (DIAS) of Saveetha Dental College and Hospitals, Chennai. It was evaluated by two independent oral pathologists trained in CRABEL scores. Two consecutive case records were evaluated. Fifty points were given for each case record. Scoring was given according to initial clerking (10 points), subsequent entries (30 points), consent (5 points), and discharge summary (5 points). The total score was calculated by subtracting the total deduction from 100 to give the final score. The mean scores of the case records were calculated. A descriptive statistical analysis was done with Statistical Package for Social Sciences (SPSS version 23.0; IBM Inc., Armonk, New York). Inter-observer agreement and reliability assessment were made using Kappa statistics.  Results From the DIAS in that period, the data of 52 cases were retrieved and reviewed. There was no proof of a reference source in the audited records, and one deduction was made to the reference score in the initial clerking, and the effective score was 98 out of 100. The mean values of 52 case records were also 98 out of 100. The observed kappa score was 1.0. There was no inter-observer bias in the scoring criteria. Both observers also gave the same scoring. Conclusion Our study illustrates that oral surgery case records in our institution were found to be accurate, as they maintained 98% of the CRABEL score value. Frequent audit cycles will help in standardizing and maintaining the quality of oral surgery case records.

Assessing the Recordkeeping Quality at the School of Dental Sciences, Universiti Sains Malaysia

INTRODUCTION

 Dental records are an essential part of dental practice. The quality of dental recordkeeping is paramount in ensuring the delivery of high-quality dental care and is also important for medico-legal reasons. Should there be any dispute or need for review, detailed and well-maintained records can provide evidence of the care provided and the decision-making process.

OBJECTIVE

The study aimed to assess the quality of dental recordkeeping and dental charting practice at the dental clinic School of Dental Sciences.

METHODS

The study was conducted in a retrospective manner reviewing dental records of patients treated by specialists, dental officers, and postgraduate and undergraduate students at the Hospital Universiti Sains Malaysia over a five-year period. Eight key components of clinical dental records i.e. date of charting, legibility on the odontogram, no blank on the odontogram, whether any mistakes have been strikethrough and initials, medical history, dental history, investigation, and treatment plan were assessed. A modified CRABEL scoring system was used to assess the quality of data retrieved from dental records.

RESULTS

The study involved the analysis of 324 case files. Among these, 90 files obtained scores ranging from 60% to 80%, with 7.7% attributed to undergraduates, 9.6% to dental officers, 6.8% to postgraduates, and 3.7% to specialists. The remaining 234 files achieved scores between 80% and 100%, with a breakdown of 17% from undergraduates, 15.4% from dental officers, 18.2% from postgraduates, and 21.3% from specialists.

CONCLUSION

 Even though the overall quality of recordkeeping in this study is good, with most records achieving a CRABEL score of 80% and above, it's important to acknowledge that ideally, each component assessed should achieve a perfect score of 100%, as it will reflect the practitioners's work.

Audit of dental record-keeping at a university dental hospital

Background

Good record-keeping is fundamental in clinical practice and essential for practising dental practitioners and those in training.

Aim

This study aimed to evaluate the level of compliance with clinical record-keeping by undergraduate dental students and staff at a university dental hospital.

Setting

The selected study setting was the Admissions and Emergency section at a university dental hospital.

Methods

A retrospective, cross-sectional review was undertaken of 257 clinical records. The CRABEL scoring system was used to evaluate 12 variables. The 12 variables included: patient name, patient hospital number, date of examination, patient main complaint, medical history, dental history, proposed treatment, proposed procedure for next visit, patient consent signature, treatment and treatment codes, student name and signature, clinical supervisor name and signature. STATA® 13 was used for descriptive analysis and all tests were conducted at 5% significance level.

Results

The median CRABEL score was 87 and interquartile range (IQR: 70-92). A CRABEL score of 100 was achieved by the students in the variable patient main complaint, indicating a 100% compliance with this variable. Other variables such as signature of supervisors showed poor compliance. The CRABEL scores showed no statistically significant difference (p = 0.86) between the students and clinical supervisors.

Conclusion

The overall audit showed that there was poor compliance with record-keeping.

Contribution

The study highlights the importance of good record keepings so that key information can be accessed for proper diagnosis and treatment of the patient. An electronic filing system presents an alternative manner of documenting medical records.

A Closed-Loop Clinical Audit of Surgical Documentation of Inpatient Records at a Tertiary Level Hospital in Egypt

BACKGROUND

Optimal record keeping is a very essential component in health care provision especially in the surgical setting. This study aimed to evaluate the quality of surgical records in wards of a surgical department at Alexandria Main University Hospital, Egypt.

METHODS

We created a systematically designed checklist using standard hospital protocol and universal guidelines presented in the previously validated STAR and CRABEL auditing tools as a basis for Yes/No questions. This checklist was then used to prospectively evaluate the quality of surgical records of patients who underwent surgery in the surgical oncology department from July 2023 to October 2023. Total STAR and section-specific STAR scores were then calculated and compared statistically.

RESULTS

A total of 80 records were randomly selected and evaluated using the STAR questionnaire. All domains showed improvement compared to the baseline except for the discharge summary which did not change from an already relatively high baseline of 96±0.0. The highest improvements were observed in the anesthetic record and operative record domains which increased from 90.65±4.3 and 86.15±5.347 to 100±0.0 and 95.6±3.365, respectively.

CONCLUSION

Our study demonstrates that significant improvements in the quality of surgical records can be achieved by simply using preprepared templates, personnel education, and systematic auditing.

Initiative to improve quality of paediatric ward-round documentation by application of 'SOAP' format

Background

Audits on record keeping practices at our multidisciplinary hospital revealed unstructured ward-round notes which were dissimilar from each other on aspects of patient information. Written as per the discretion of the rounding physician, the practice compromised team communication and medicolegal safety and risked patient harm. Paediatricians decided to address this concern for their department and proposed to improve the quality of documentation by structuring their notes using subjective, objective, assessment and planning (SOAP) format. On observing only 13% compliance with SOAP use despite education and training to use it, a series of interventions were explored to increase its application.

Methods

Brainstorming sessions with the paediatricians provided practical solutions. These were tested one by one using plan–do–study–act cycles to understand their impact. Team feedback was pursued towards the end of each cycle to understand the opinion of each team member.

Interventions

Interventions included verbal reminders, individual feedback and SOAP acronym display. Each of these were tested singularly and serially. Acronym display proved successful until the arrival of COVID-19, which disrupted its implementation and redirected paediatricians’ work priorities. This led to exploration of a new solution, and paediatricians recommended use of visual reminders at the handover site. Quantitative information was analysed to reject or retain the ideas.

Results

Verbal reminders and individual feedback made no difference to SOAP usage. Acronym display improved compliance from 13% to 90% but it fell to 45% during COVID-19. Its replacement with visual reminders during pandemic times reinstated the compliance to a median of 84%.

Conclusions

Selection of a change idea that respected front liner’s constraints and suited local work environment proved valuable. Both acronym display and visual reminders served as visual reinforcements towards embracing a note format and proved effective. Perceived benefits from methodically written notes encouraged paediatricians to re-establish simpler measures to retain SOAP application, otherwise disrupted during the COVID-19 pandemic.

The surgical admission proforma: the impact on quality and completeness of surgical admission documentation

BACKGROUND

Inadequate medical documentation has been associated with a higher rate of adverse events and may have medicolegal consequences. An accurate admission note is critical as it is frequently referred to during inpatient stay, particularly when the patient is acutely unwell and during handover of care.

AIM

We set out to implement a surgical admission proforma and evaluate its impact on the quality of acute surgical admission notes.

METHODS

A standardised, structured admission proforma for use with all emergency general surgery patients in a busy model 3 hospital was designed and implemented. Previously, all admission notes were performed freehand. The quality and completeness of admission notes was evaluated both before and after implementation of the proforma over two separate 4-week periods by assessing documentation across 19 criteria.

RESULTS

Two hundred and fifty-one admission notes before proforma implementation and 273 admission notes after implementation were assessed. Proforma uptake was 97%. Documentation improved in all 19 criteria, with statistical significance achieved in 17 of these. These include past medical history, medication lists, allergy status, physical examination findings, blood results, vital signs and management plan. The proforma showed evidence of improved communication with both nursing staff and senior colleagues.

CONCLUSIONS

The surgical admission proforma has significantly improved the quality and completeness of admission documentation, ensuring improved patient safety and efficiency of care. Structured admission proformas have a positive impact on patient outcomes, doctors' performance, hospital efficiency, communication and audit quality control, thus providing multiple clear benefits in comparison to freehand admission notes.

Improving the surgical consenting process for patients with acute hip fractures: a pilot quality improvement project

Background

Consenting patients for trauma procedures following hip fracture is a key stage in the treatment pathway from admission to the operating theatre. Errors in this process can result in delayed procedures which may negatively impact patient recovery. The aim of this project was to identify and reduce errors in our consenting process for patients with capacity.

Methods

Consent forms for all adult patients with capacity admitted for surgical repair of traumatic hip fracture were reviewed over a 4-week period. The baseline measurement (n = 24), identified errors in three key process measures: clarity of documentation, failure to record procedure-specific risks and not offering a copy of the consent form to the patient. Pre-printed stickers and targeted teaching were then introduced as quality improvement measures. Their impact was evaluated over subsequent 4-week review of the same patient demographic, with further refinement of these interventions being carried out and re-evaluated for a final cycle.

Results

Cycle 1 (n = 26) following targeted teaching demonstrated a reduction in abbreviations from 38 to 20%, while doubling the documentation of discussion of procedure-specific risks from 31 to 72%. More patients were offered a copy of their consent form, rising from 12 to 48%. Cycle 2 (n = 24) saw the introduction of pre-printed "risk of procedure" stickers. Although clarity measures continued to improve, quality of pre-procedure risk documentation remained static while the number of forms being offered to patients fell to 8%.

Conclusions

Our project would suggest that while pre-printed stickers can be useful memory aids, specific teaching on consenting produces the greatest benefit. The usage of such tools should therefore be limited, as adjuncts only to specific training.

The DATA protocol: developing an educational tool to optimise note-writing in hospitals

BACKGROUND

Good clinical record-keeping is central in ensuring patient safety and effective communication between healthcare professionals. Poor communication is the root cause of many adverse events in medicine.

AIMS

To assess the standard of notation for surgical inpatients, to create and pilot an educational tool to improve the quality of documentation, and to assess the adequacy of intern training in this area.

METHODS

Healthcare records were retrospectively assessed during the first audit cycle for inclusion of basic criteria as per the current guidelines from the Health Service Executive. The intervention comprised a teaching session and an educational tool which was designed utilising the mnemonic DATA (date and time, addressograph, team, author details). A second audit cycle was carried out prospectively. Irish interns were also surveyed to assess the level of training they had received with regard to clinical record-keeping. Comparative analyses of quantitative data were performed using chi-squared test for categorical variables.

RESULTS

A total of 200 notes were analysed. Those written after the intervention were significantly more likely to contain patient details, time seen, author name, job title, bleep number, and medical council registration number. Of the 59 interns who responded to the survey, 78% had not received training on how to properly write a clinical note and many had simply copied the format of notes written by the previous team. Very few had been made aware of the national guidelines available for record-keeping.

CONCLUSION

The use of the educational tool and a formal training session significantly improved the quality of notes written for surgical inpatients. Junior doctors do not feel adequately trained in this area. The authors recommend that formal training in record-keeping be included in all hospital induction programmes.

Completeness in clerking: The surgical admissions proforma

BACKGROUND

The accessibility of surgical patient data is a key safety concern, and relies on efficient clerking and handovers. This project assessed whether the introduction of a surgical clerking proforma improved the recording of patient information in the surgical admissions unit (SAU) at Northwick Park Hospital.

MATERIALS AND METHODS

Existing patient notes were assessed on content and ease of access, using two independent surveys conducted over a 5-day period. The first survey audited patient notes before (n = 28) and after (n = 23) the introduction of the proforma. It assessed whether key patient details were documented, in line with the 17 criteria set out in the Guidelines for Clinicians on Medical Records and Notes by The Royal College of Surgeons in England. The second survey questioned healthcare professionals before (n = 25) and after (n = 17) proforma implementation on the accessibility of patient data and coherency of patient notes.

RESULTS

5 of the 17 criteria showed significant differences post proforma implementation. Of these differences, the recording of height and occupation was most notable (p < 0.01). Medication history, weight and investigations also showed significant increases in documentation (p < 0.05). In all 3 questions asked to healthcare professionals, fewer healthcare professionals were required to revisit archived notes following proforma implementation (p < 0.05).

CONCLUSION

Our study illustrates that a comprehensive surgical clerking proforma improves patient data documentation and saves healthcare professionals' time compared to the freehand clerking method. The implications of such work are far reaching, and if well implemented could allow a new reliable platform for further clinical audits.

The e-CRABEL score: an updated method for auditing medical records

In 2001 the CRABEL score was devised in order to obtain a numerical score of the standard of medical note keeping. With the advent of electronic discharge letters, many components of the CRABEL score are now redundant as computers automatically include some documentation.

The CRABEL score was modified to form the e-CRABEL score. “Patient details on discharge letter” and “Admission and discharge dates on discharge letter” were replaced with “Summary of investigations on discharge letter” and “Documentation of VTE prophylaxis on the drug chart”. The new e-CRABEL score has been used as a monthly audit tool in a busy surgical unit to monitor long-term standards of medical note keeping, with interventions of presenting in the departmental audit meeting, and giving a teaching session to a group of junior doctors at two points.

Following discussion with stakeholders: junior doctors, consultants, and the audit department; it was decided that the e-CRABEL tool was sufficiently compact to be completed on a monthly basis. Critique and interventions included using photographic examples, case note selection and clarification of the e-CRABEL criteria in a teaching session.

Tools used for audit need to be updated in order to accurately represent what they measure, hence the modification of the CRABEL score to make the new e-CRABEL score. Preliminary acquisition and presentation of data using the e-CRABEL score has shown promise in improving the quality of medical record keeping. The tool is sufficiently compact as to conduct on a monthly basis, maintaining standards to a high level and also provides data on VTE documentation.

The use of a pro forma to improve quality in clerking vascular surgery patients

At our institution, a large tertiary referral centre for vascular surgery, patients are often admitted directly to the ward and clerked by foundation year one (FY1) doctors. We found that these clerkings frequently fell short of national record keeping standards, potentially leading to an increased risk for patients during their hospital stay. In addition, we found that junior doctors did not feel confident in clerking vascular surgery patients.

A literature review found that high quality clerkings were strongly linked to improved patient safety, and that the use of a pro forma was one method to improve compliance with documentation guidelines. We devised a clerking pro forma based on national guidelines and introduced it to the department.

We found that the use of a pro forma significantly improved documentation standards across a number of domains, including patient demographics, presenting complaint, and family and social histories (p <0.05). Examinations were significantly more comprehensive, with cardiac and vascular examination as well as peripheral pulses documented (p <0.05).

In conclusion, we found that using a pro forma helped to aid junior doctors in clerking new patients, and significantly improved the quality of their history and examinations. This leads to a potential positive impact on patient safety during their inpatient stay, and should be rolled out more widely across the hospital.

The surgical admissions proforma: Does it make a difference?

Admissions records are essential in communicating key information regarding unwell patients and at handover of care. We designed, implemented and evaluated the impact of a standardised surgical clerking proforma on documentation and clinician acceptability in comparison to freehand clerking. A clerking proforma was implemented for all acute general surgical admissions. Documentation was assessed according to 32 criteria based on the Royal College of Surgeons of England guidelines, for admissions before (n = 72) and after (n = 96) implementation. Fisher's exact test and regression analysis were used to compare groups. Surgical team members were surveyed regarding attitudes towards the new proforma. Proforma uptake was 73%. After implementation, documentation increased in 28/32 criteria. This was statistically significant in 17 criteria, including past surgical history (p < 0.01), medication history (p = 0.03), ADLs (p = 0.02), systems review (p < 0.01), blood pressure (p < 0.01), blood results (p = 0.02) and advice given to the patient (p = 0.02). The proforma remained beneficial after regression analysis accounted for differences in time of day, seniority of the doctor and nights or weekends (coefficient = 0.12 [p < 0.01]). 89% of the surgical team felt the form improved quality of documentation and preferred its use to freehand clerking. 94% felt it was beneficial on the post-take ward-round. Audit quality control was also more reliable with the proforma (inter-observer agreement = 99.3% [κ = 0.997]) versus freehand clerking (97.1% [κ = 0.941]). Our study demonstrates that a standardised surgical clerking proformas improves the quantity and quality of documentation in comparison to freehand clerking, is preferred by health professionals and improves reliability of the audit quality control process.

Surgical hospital audit of record keeping (SHARK)--a new audit tool for the improvement in surgical record keeping

INTRODUCTION

Accurate and legible record keeping is a crucial part of good medical practice. Surgical Hospital Audit of Record Keeping (SHARK) is a new audit and teaching tool for junior doctors. The author has designed the tool, based on the Royal College of Surgeons guidelines, to anonymously score the different surgical teams' medical records within a hospital. It takes into account regular record keeping during ward rounds, together with the operation note and admission clerking.

METHODS

The SHARK audit tool assesses 45 individual areas within surgical records. Fifteen points are apportioned for an initial surgical clerking, 13 for a subsequent record entry, and 17 for the operation note to give an overall score out of 45. It was implemented at 2 hospitals and used to educate medical students.

RESULTS

The results were poor and improved with education at both sites. There was 80% total agreement with a κ coefficient for interobserver reliability of 0.6.

CONCLUSION

This study shows that the SHARK tool is simple to use, repeatable, and reliable in improving record keeping.

Data recording aids in acute admissions

PURPOSE

Clinical data capture and transfer are becoming more important as hospital practices change. Medical record pro-formas are widely used but their efficacy in acute settings is unclear. This paper aims to assess whether pro-forma and aide-memoire recording aids influence data collection in acute medical and surgical admission records completed by junior doctors.

DESIGN/METHODOLOGY/APPROACH

During October 2007 to January 2008, 150 medical and 150 surgical admission records were randomly selected. Each was analysed using Royal College of Physicians guidelines. Surgical record deficiencies were highlighted in an aide-memoire printed on all A4 admission sheets. One year later, the exercise was repeated for 199 admissions.

FINDINGS

Initial assessment demonstrated similar data capture rates, 77.4 per cent and 75.9 per cent for medicine and surgery respectively (Z = -0.74, p = 0.458). Following the aide-memoire's introduction, surgical information recording improved relatively, 70.5 per cent and 73.9 per cent respectively (Z = 2.01, p = 0.045). One from 11 aide-memoire categories was associated with improvement following clinical training. There was an overall fall in admission record quality during 2008-9 vs 2007-8.

RESEARCH LIMITATIONS/IMPLICATIONS

The study compared performance among two groups of doctors working simultaneously in separate wards, representing four months' activity.

PRACTICAL IMPLICATIONS

Hospital managers and clinicians should be mindful that innovations successful in elective clinical practice might not be transferable to an acute setting.

ORIGINALITY/VALUE

This audit shows that in an acute setting, over one-quarter of clinical admission data were not captured and devices aimed at improving data capture had no demonstrable effect. The authors suggest that in current hospital practice, focussed clinical training is more likely to improve patient admission records than employing recording aids.

The STAR score: a method for auditing clinical records

INTRODUCTION

Adequate medical note keeping is critical in delivering high quality healthcare. However, there are few robust tools available for the auditing of notes. The aim of this paper was to describe the design, validation and implementation of a novel scoring tool to objectively assess surgical notes.

METHODS

An initial 'path finding' study was performed to evaluate the quality of note keeping using the CRABEL scoring tool. The findings prompted the development of the Surgical Tool for Auditing Records (STAR) as an alternative. STAR was validated using inter-rater reliability analysis. An audit cycle of surgical notes using STAR was performed. The results were analysed and a structured form for the completion of surgical notes was introduced to see if the quality improved in the next audit cycle using STAR. An education exercise was conducted and all participants said the exercise would change their practice, with 25% implementing major changes.

RESULTS

Statistical analysis of STAR showed that it is reliable (Cronbach's α = 0.959). On completing the audit cycle, there was an overall increase in the STAR score from 83.344% to 97.675% (p < 0.001) with significant improvements in the documentation of the initial clerking from 59.0% to 96.5% (p < 0.001) and subsequent entries from 78.4% to 96.1% (p < 0.001).

CONCLUSIONS

The authors believe in the value of STAR as an effective, reliable and reproducible tool. Coupled with the application of structured forms to note keeping, it can significantly improve the quality of surgical documentation and can be implemented universally.

Accuracy, legibility, and content of consent forms for hip fracture repair in a teaching hospital

OBJECTIVE

The purpose of our study was to assess the accuracy, legibility, and content of consent forms for hip fracture surgery in elderly patients.

METHODS

We performed a retrospective review of 116 patients older than 65 years who underwent surgical correction of hip fractures at a major US teaching hospital in 2005 and 2006. Accuracy was assessed by comparing the description of the operative procedure on consent forms and in electronic patient records. Legibility of consent forms was assessed with the Legibility Index. Content of consent forms was assessed with a complication score and the Crawford-Beresford-Lafferty score. Content of the operative procedure section on consent forms was further checked for readability using the Flesch Reading Ease score and the Flesch-Kincaid Grade Level.

RESULTS

Consent forms had a mean ± SD Legibility Index score of 3.4 ± 0.5. The mean complication and Crawford-Beresford-Lafferty scores were 8.0 ± 2.1 and 4.4 ± 0.7, respectively. With regard to operative procedure section readability, the mean Flesch Reading Ease score was 32.4 ± 18.4, and the mean Flesch-Kincaid Grade Level was 13 ± 3.1.

CONCLUSIONS

On the basis of the results, we found that consent forms for hip fracture surgery at this hospital were accurate in describing operative procedures. Consent forms were legible but written at high reading grade levels and were deficient in including all possible complications related to hip fracture repair. In conclusion, medical documentation and the informed consent process for hip fracture surgery in the elderly can be improved.

Adequacy of immediate care documentation at a major United Kingdom endurance event

The objective of this study was to determine the rate of major omissions from documentation in a prehospital environment. Analysis of 251 competitor records, documented over 2 years from four consecutive UK outdoor endurance events (2006-2007), was performed. Eighty-two percent of case notes were found to be of adequate quality (n = 206), with 15% containing minor omissions (n = 37, i.e. omissions of some patient details) and 3% containing major omissions (n = 8, i.e. no details of diagnosis/treatment). Of the major omissions, first aiders and health-care professionals (doctors and nurses) made the same number of errors (n = 4 each, P = 0.7), but first aiders made significantly more minor omissions (n = 31 vs. 6, P<0.001). From 25 patients who needed medication, only one prescription error occured. In conclusion, accurate documentation is achievable at prehospital mass gathering events. First aiders made no more major documentation omissions than health-care professionals, but made more minor omissions. Standardized proformas may help reduce this rate and improve efficiency.

Quality of clinical notes for vascular surgery admissions: a CRABEL score review

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.