The Royal College of Surgeons of England

Ann R Coll Surg Engl 2001; 83: 65-68

Surgical audit

The CRABEL score - a method for auditing
medical records
JR Crawford, TP Beresford, KL Lafferty
Department of Surgery, Basildon Hospital, Essex, UK

Medical record keeping has become increasingly important particularly for research, audit and medico-legal purposes. The authors present a protocol, the CRABEL score, that is quick and easy to use for the assessment of the quality of medical record keeping with the purpose of standardizing the audit of medical records and improving their quality.
Key words: Medical records Audit

Good note keeping is fundamental to good clinical practice. Medical records have become tools for many parties with widely differing interests1 and are essential for retrospective reviews for audit2 and for their medico-legal implications. The Royal College of Surgeons of England has produced guidelines for audit and outlined its importance.3 In 1990, it subsequently published guidelines on medical records and notes4 to be used as a standard for note keeping. However, it has been shown that the extent to which medical records follow these guidelines is inadequate.5 Based on The Royal College of Surgeons of England guidelines, we have formulated a system for assessing the quality of medical note keeping the CRABEL score (CRAwford BEresford Lafferty). By attributing a numerical score to the assessment, comparisons can be made between the standard of note keeping between individual firms, different specialties and even between hospitals.

Materials and Method
The auditor selects two sets of medical notes at random for each consultant firm to be assessed, from the discharge pile of notes awaiting formal discharge summaries (or completion of front sheets). Initially, a mark of 50 points is allocated to each set of notes giving a total mark of 100 for one particular firm. The most recent or current admission from each set of notes is analysed using the CRABEL scoring sheet (Fig. 1). Points are deducted from the initial score in accordance with the protocol by marking the appropriate boxes. The number of marked boxes in each column is then counted to give the number of points deducted for each set of notes, and the sum of the two columns is the total deductions. The CRABEL score is calculated by subtracting the total deductions from 100 to give a 'per cent' score. The balance of points is spread between four sections so there is a limit to the maximum number of



Correspondence to: Dr JR Crawford, 16 Pinegarth, Darras Hall, Ponteland, Newcastle-upon-Tyne NE20 9LF, UK
Ann R Coll Surg Engl 2001; 83


[10] [ U O U U U U U U U U O O U U U U U U U UUUUU UUUUU UUUUU UUUUU SUBSEQUENT ENTRIES patient name and number date and time heading results [30] UUUUU UUUUU UoUUU UUUUU legibility signature / name / post / bleep no.CRAWFORD THE CRABEL SCORE . CONSENT patient name hospital number operation in full risks / complications signatures UUUUU DOOOO U UOOU UUUUU U U U U U U U U U Ul [5] U U U U U DISCHARGE LETTER patient details admission / discharge dates diagnosis / management drugs follow-up TOTAL DEDUCTIONS [5] U U U U [ ] + [ % ] = CRABEL SCORE (100 .A METHOD FOR AUDITING MEDICAL RECORDS THE CRABEL SCORE Firm: MARKING PROFORMA patient initials INITIAL CLERKING patient name patient hospital number referral source consultant date / time diagnosis management plan investigation results clinician signature clinician name / post / bleep no.DEDUCTIONS) = Figure 1 The CRABEL score marking proforma 66 A nn R CQl zfrlr PI tltJ[ Surg Engl 2001. 83 .

post and bleep number printed clearly underneath (1 point deductible for each). at any one audit meeting. However. start antibiotics. (iv) admitting consultant.generally any entry with two or more illegible words should be deducted 1 point up to a maximum of 5 points (particularly poor examples of handwriting may be photocopied onto overheads for further analysis during the audit meeting!). (v) legibility is at the discretion of the auditor . Ann R Coll Surg Engl 2001.g.g. (iv) hospital number. (ii) date of each entry and time if appropriate. the CRABEL score can be used to monitor the standard of note keeping within a particular firm at consecutive audits. (ix) clinician must sign clerking. W/R consultant. Omission of any of the following details outlined in bold print results in a deduction of the number of points indicated. (vi) working diagnosis or differential diagnosis clearly stated. post and bleep number printed underneath the appropriate signature. name and address. Consent (5 points) One point is deducted for omission of any of the following details: (i) operation in full without abbreviations must be stated on consent form. GP. a numerical score (out of 100) is calculated that can be used as a representative value for that firm. scores were achieved in the range 50-90. e. (iii) referral source must be entered. and (v) follow-up plans. abbreviations are acceptable (1 point). e.g. nil by mouth. the King's Fund has also produced medical record accreditation.THE CRABEL SCORE . e. (ii) risks/complications of procedure explained to the patient must be documented. (v) date and time of clerking must be present.g. but we do aim to compare the standard of note keeping between different specialties in the near future. FBC. easy and reproducible method for assessing and evaluating how closely these guidelines are adhered to. with the clinician's name. By analysing two sets of medical notes. etc.3 In addition to The Royal College of Surgeons of England guidelines. Using the CRABEL score The marking proforma is shown in Figure 1. position and bleep number. e. Discussion Medical records are the only lasting interpretation of the physician-patient interaction. The CRABEL score is a quick.A METHOD FOR AUDITING MEDICAL RECORDS CRAWFORD points lost in any one section to reduce bias from repeated identical errors. (iii) patient's name. Reproducing actual data in this paper achieves nothing. Initial clerking (10 points) One point is deducted for each omission of any of the following details: (i) Patient name at top of history sheet. Over the year that the CRABEL score was first introduced. (iii) appropriate heading must commence each entry. and (x) clinician must print name. patient seen on-call (1 point deducted for either). (vii) initial management plan. and (vi) each entry must be signed. Subsequent entries (30 points) One point is deducted for omission of each detail in bold up to a maximum of 5 points for each sub-section: (i) patient name and hospital number at the top of each history sheet (1 point deducted for omission of either to a maximum of 5 points). or for comparison between different firms. (iv) medication on discharge. We found that scores typically increased over consecutive audits. 83 Initial discharge letter (5 points) One point is deducted for omission of any of the following: (i) patient details. It was our experience that the most common cause for loss of points was failure to accompany each entry in the notes by the clinician's surname. It has previously been shown that regular audit of case notes can achieve significant improvement in 67 .' and medico-legal problems may arise from a low standard of medical record keeping. the scores obtained across all the firms were usually within a range of 20 points. Results The CRABEL score has been adopted at Basildon Hospital as part of the general surgery departmental audit for the last two years. e. (ii) patient hospital number at top of history sheet. (iv) results of investigations requested should be documented (1 point) as X-ray reports and blood results often become mis-filed or lost from the back of the notes. We also found that the method is easily transferable to successive junior medical staff.g. and (v) signatures of clinician and patient/ guardian. (viii) results of initial investigations performed.g. ensuring monthly revisiting of the audit loop. e. asked to see. A+E. As the scoring system is universal. (ii) admission and discharge dates. Using the CRABEL score can become a fixed agenda item in audit meetings. (iii) diagnosis and management. It is our experience that this can instigate healthy competition with prizes on occasions being awarded for achieving a perfect score of 100.

1): 7-9. 17: 208-12. J R Coll Physicians Lond 1991. Guidelines for Clinicians on Medical Records and Notes. It should be noted that. Morgan JM. London: The Royal College Surgeons of England. Notes: a suitable case for audit. As documentation has a critical role in medico-legal cases. 10. 11. 1990."1 The CRABEL score does not do this but simply audits the quality of the actual medical record keeping. simple and reliable method for auditing the quality of medical records. 25: 358-9. McInnes E. Improving problem orientated medical records through self audit. A year's experience of auditing case notes. post and bleep number. 300: 991-3. 3: 291-2. Williams JG. 6. 3. Phongsathom V. Random review of hospital patient records.A METHOD FOR AUDITING MEDICAL RECORDS record keeping. Previous studies have audited the actual content of medical notes. 300: 651-2. Swansea Physicians' Audit Group. BMJ 1990. It is hoped that this may induce constructive habits to be formed so. Twigg J. The Royal College Surgeons of England. 1989. Guidelines to Clinical Audit in Surgical Practice. we intend to present data in the near future comparing the standard of medical note keeping between different specialties.7 This may be attributable to those clinicians responsible for writing in the notes taking more care as they are aware that their documentation may undergo close scrutiny. correct identification of clinicians from the medical records is essential. Audit of the quality of medical records in a district general medicine unit. Heath DA. 236: 533-5. Rai GS. Sharland DE. Postgrad Med J 1993. London: The Royal College of Surgeons. Medical audit of case notes on a one to one basis. The authors propose the use of the CRABEL score as a quick. Inadequacies of hospital medical records. The Royal College Surgeons of England. Sharland DE. 10: 487-90. 7. J R Coll Physicians Lond 1983. Bielawska C. 68 Ann R Coll Surg Engl 2001. 9. Davies AB. 83 . Miller R. Practitioner 1992. Kalra D. Mould T. Retrospective review of hospital patient records. Ann R Coll Surg Engl 1993. the quality of medical records is ultimately the responsibility of the consultant9 and so this is one possible method that could be used to help improve consistency. 4. 69: 578-80. 2. BMJ 1990. Care Elderly 1991. J Fam Pract 1980. Briggs T. Rai GS.CRAWFORD THE CRABEL SCORE . Medical records. The CRABEL scoring system may be universally applied to any in-patient specialty including all branches of medicine and surgery. References 1. that a clinician's signature in the notes is automatically followed by a printed name. Parker C. Kingham MJ. Webb PJ. Bass MJ. 5. It is also adaptable between different hospitals irrespective of the different formats of medical record keeping. Patel AG. 8. for example. Dickie GL. although most of the information in hospital case notes is written by junior staff. 75 (Suppl.89 appropriateness of management10or the presence of results and information.