Abstract

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.