British Journal of Oral and Maxillofacial Surgery (2004) 42, 200—202

The CRABEL score–—setting standards inmaxillofacial medical note-keeping

D.K. Dhariwal*, A.J. Gibbons

Maxillofacial Unit, Oral and Maxillofacial Surgery, Morriston Hospital, Swansea SA6 6NL, Wales, UK

Accepted 28 January 2004

KEYWORDSAudit;Medical note-keeping

Summary The CRABEL score (developed by Crawford, Beresford and Lafferty) wasintroduced for auditing medical note-keeping at Morriston Hospital in June 2001.Guidelines detailing the scoring systemwere issued to all clinicians in themaxillofacialunit. An auditor selected two sets of medical notes from each consultant’s firm, givingan initial allocation of 100 points/firm (50 points for each set of notes). The notes ofthe most recent in-patient admission were analysed using the CRABEL marking sheetto give a score out of 100 for each firm. The audit was repeated at 3-month-intervals.CRABEL scores within the maxillofacial unit improved from 70 to 97. The CRABEL scoreis simple, reliable and repeatable. It is a successful and objective measure for auditand for improvement in the quality of note-keeping. We propose that it be adoptedin maxillofacial units throughout the United Kingdom.© 2004 The British Association of Oral and Maxillofacial Surgeons. Published by ElsevierLtd. All rights reserved.

Introduction

Good medical note-keeping is essential for the careof patients, and for research, audit, and for medi-colegal purposes. Nevertheless, there are grossinadequacies in the standard of note-keeping.1—3

When little or no information is sent to generalmedical practitioners after a patient’s dischargefrom hospital, there may be a spill-over of prob-lems into primary care.3

Standard proformas improve note-keeping byacting as an aide memoire for junior doctors. How-ever, improvement is only sustained as long asregular audit is continued.4 Review of patients’hospital records and presenting the results to ju-nior doctors in a friendly and non-confrontational

*Corresponding author. Tel.: +44-1792-703515;fax: +44-1792-703068.

E-mail address: daljitdhariwal@hotmail.com (D.K. Dhariwal).

manner raises the standards of note-keeping andcan be enjoyable. It is even more valuable if sup-ported by consultants who believe in its benefitand who regularly attend audit meetings.5

A trial of self audit in general medical practiceusing a numerical scoring system that compared selfaudit with a control group showed that self audit isa useful stimulus to good note-keeping. However,adequate time must be set aside for it.6

The Royal College of Surgeons of England hasgiven clear guidance on the details that are re-quired in hospital case-notes.7 Although most of theinformation is recorded by junior staff, the qualityof the records is ultimately the responsibility ofthe consultant, who should monitor the recordingin individual case-notes and educate junior staffas necessary.2 Notes should be legible, contempo-raneous, unambiguous, signed, dated and timed,with the patient correctly identified on each sheet.These points form the basis of the CRABEL score,8

which is a quick, easy, and standardised method for

0266-4356/$ — see front matter © 2004 The British Association of Oral and Maxillofacial Surgeons. Published by Elsevier Ltd. All rights reserved.doi:10.1016/j.bjoms.2004.01.013

The CRABEL score 201

the assessment of medical note-keeping. It gives anumerical score for the essential aspects of medi-cal note-keeping, and allows comparison betweenfirms, specialties and hospitals.We aimed to introduce this simple objective mea-

sure for auditing medical note-keeping in our unitas it was quick, reliable, and regularly repeatable(in our case every 3 months).

Methods

To assess baseline standards, the CRABEL score wasapplied to two sets of medical records selected ran-

Table 1 CRABEL score.

One point is deducted for each omission of any ofthe following details

Initial clerking (10 points)• Patient’s name (at top of history sheet)• Patient’s hospital number (at top of historysheet)

• Referral source (general practitioner, dentist,A&E department)

• Admitting consultant• Date/time of clerking• Working diagnosis or differential diagnosis• Management plan• Results of investigations• Signature of clinician at end of clerking• Name, post and bleep number of clinician (alldetails required)

Subsequent entries (up to 6 entries, 30 points)• Patient’s name and number at the top of eachhistory sheet

• Date and time of each entry• Heading (ward round and consultant’s name)• Results (to be documented in notes)• Notes should be legible• Signature, name, post and bleep numberclearly printed at the end of each entry

Consent (5 points)• Patient’s name at top of sheet• Hospital number at top of sheet• Operation in full without abbreviations• Risks or complications appropriate to theprocedure documented

• Signatures of clinician and patient or guardian

Discharge letter (5 points)• Patient’s details (name and address)• Admission and discharge dates• Diagnosis and management• Medication on discharge• Follow-up plans

domly from different hospital specialties before weintroduced it to the maxillofacial unit. Guidelinesfor the expected standard of note-keeping with acopy of the marking proforma were then issued toall clinical staff in the maxillofacial unit in June2001, with instructions that notes would be auditedevery 3 months. Each set of case-notes was allo-cated a total of 50 points. The initial clerking sec-tion was given 10 points; the subsequent entries30 points with up to 6 entries being assessed and5 points given for each entry; consent was given5 points, and the discharge letter 5 points. Onepoint was deducted for each omission (Table 1).The notes of two patients from each consultant firmwere analysed at each audit to give a maximumpossible score of 100 points for each firm. The goldstandard was 100 points.Notes were reviewed from each of the four max-

illofacial consultant firms 1 month after introduc-tion, and then in 3-monthly intervals. Feedback wasgiven to clinical staff at audit meetings. A secondhospital-wide audit by speciality was done 1 yearafter we had introduced the audit to the maxillofa-cial unit. No other speciality introduced the CRABELscoring system during this period.

Results

Before the introduction of the CRABEL score, 70was scored in maxillofacial surgery compared with40 in neurosurgery and 60 in orthopaedics. A yearafter the introduction of the CRABEL audit in max-illofacial surgery a score of 97.5 was achieved,which compared favourably with other special-ties (Fig. 1). There was no similar improvementin orthopaedics or neurosurgery, who did not au-dit their note-keeping. CRABEL scores within the

Figure 1 CRABEL scores by speciality June 2002.

202 D.K. Dhariwal, A.J. Gibbons

Table 2 CRABEL scores by consultant’s firm in themaxillofacial unit, June 2001—February 2003 (two setsof case-notes were assessed on each occasion).

Date Consultant’s firm

A B C D

2001June 70 70 70 70July 86 89 96 87September 87 83 90 87December 95 97 94 98

2002February 96 97 86 85June 96 100 97 97August 94 92 96 93November 96 100 96 94

2003February 98 95 95 99

maxillofacial unit improved from June 2001 toFebruary 2003 from a mean of 70 (range 60—80) to97 (range 95—99) with a sustained improvement inthe quality of note-keeping (Table 2).Analysis of the scores in each category allowed

areas of strength and weakness to be identified,which were presented to the junior staff at au-dit meetings. Common areas of weakness includedomission of times of review, bleep numbers, admis-sion and discharge dates on discharge letters, andabsence of the results of investigations from thenotes. These areas were all improved by the au-dit. Areas of strength were praised and if anyoneachieved a CRABEL score of 100, they were congrat-ulated at the meeting.

Discussion

Our audit showed that the CRABEL score can besuccessfully introduced into a busy maxillofacialunit and lead to an improvement in the stan-dard of medical note-keeping. Induction coursesfor junior staff are an ideal time to distributeguidelines.9 The audit spiral should then becontinued in a non-judgemental atmosphere at3-month-intervals.10 We gave specific feedback on

areas of strength and areas that required improve-ment in each firm’s note-keeping. This fostered afriendly rivalry between junior staff that helped toraise standards. The improvement in the quality ofmedical note-keeping in our audit was sustainedthroughout changes in junior staff.With the impending implementation of the Eu-

ropean Working Time Directive,11 communicationthrough good note-keeping will become increas-ingly important as juniors will be unable to provide24-h continuity of care. Good note-keeping alsofacilitates other audit projects.10

We recommend the CRABEL score as an effec-tive way of auditing and improving medical note-keeping.

Acknowledgements

We thank Mr D.W. Patton, Mr A.W. Sugar, Mr K.C.Silvester and Mr S.C. Hodder for their permission toinclude their patients in this audit.

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