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Use of CRABEL Scores to improve Quality of Medical Records Documentation in Hospitals

Introduction: This study is based on an approach employed by a medical college hospital for improving the adequacy of documentation in their medical records. The hospital utilized CRABEL scoring tool to screen and score their medical records and then used this information as a feedback to their clinical departments for encouraging them to improve their record documentation. Aim: The study aims to determine whether the approach of the hospital resulted in any significant change in adequacy of their medical record documentation. Materials and methods: Baseline sample of 250 current medical records (stratified random) from four clinical depart ments were scored using CRABEL scoring method to determine baseline average score and number of files with high scores (score > 0.85). Feedbacks on scores were given to departments, along with the information on areas for improvement. Scoring and feedback were repeated every month for six consecutive months, with sample size of 230 to 271. Trends in average score and number of files with high scores were observed. Difference between average scores of baseline sample and sample at the end of 6 months was statistically tested. Number of files with high scores, in departments where approach was carried out was compared with number of files with high scores, in depart ments were approach was not carried out, to check statistically significant difference, if any Results: The trend showed a continuous monthly improvement in both average scores and number of files with high scores. Improvement was found in files of all clinical departments with minor variations. The chi-square test and Student’s t test showed a significant difference at p < 0.05 (p for chi square – 0.001 and for t-test – 0.04). Conclusion: The hospital’s approach was found to be successful in improving the adequacy of documentation in medical records. Clinical significance: Medical record constitutes the most important record in a clinical setting. Completeness of medical record is essential for proper patient care, but is a challenge in most organization. The approach proven successful in this study can be replicated in other settings for of CRABEL