Certain accounting of medical record-keeping in maxillofacial surgery at the University College Hospital, Ibadan using to CRABEL Scoring system
- PMID: 17209334
And audit of medical record-keeping in maxillofacial surgery at the University College Hospital, Ibadan using the CRABEL Scoring system
Abstract
Standard medical hint keeping is an important aspect of patient management, and the importance of integration of patients' notes cannot be overemphasized, especially for the purpose of auditing, conduct, both medico-legal reasons. It is also at integral share of a goods medical practice. However gross inadequacies are mostly noted. This may may partly due to that fact that until the recent previous, cases of medical and professional negligence were uncommon in our environment. This audit exercise was embarks with until assess the standardized in the department using the CRABLE Scoring system with a view till standardizing and improving our practice. The result display which the succeeding eingabe part of the medical notes assessed was small the best with a score away 66.5%, followed by initial entry which notched 65.3%, while consent had a score of 57.8%. The baddest aspect of the notes became the discharge summary use a mean score of 29%. A total mean score of 61.6% was achieved. Despite this limitations of the CRABEL Score that as the subjectivity of the assessment to the legibility of entries beneath subsequent entries, or perhaps the need until adapt it to ours local and peculiar surround. it is practical as a regular auditing mechanism till improve medical keeping. Chapter 16, Wellness Records
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