An audit of medical record-keeping in maxillofacial surgery nt the UniversityColIege Hospital, Ibadan using the CRABEL scoring system.

Abstract

Standard medical note keeping is an important aspect of patient management, and the importance of completeness of patients* records cannot be overemphasized, especially for the purpose of auditing, research, and medico-legal reasons. It is also an integral part of a good medical practice. However gross inadequacies are often noted. This may be partly due to the fact that until the recent past,cases of medical and professional negligence were uncommon in our environment. This audit exercise was embarked upon to assess the standard in the department using the CRABLE Scoring system with a view to standardizing and improving our practice. The result showed that the subsequent entry part of the medical notes assessed was marginally the best with a score of 66.5%. followed by initial entry which scored 65.3%. while consent had a score of 57.8%. The worst aspect of the notes was the discharge summary with a mean score of 29% . A total mean score of 61.6% was achieved. Despite the limitations of the CRABEL Score such a s the subjectivity of the assessment of the legibility of entries under subsequent entries, and perhaps the need to adapt it to our local and peculiar environment, it is useful as a regular auditing mechanism to improve medical keeping.