Background Oral surgical records contain all the information regarding a patient, including their history, clinical findings, diagnostic test results, pre-and postoperative care, progress, and medication. Notes that are properly drafted will help the physician argue that the course of therapy is appropriate. Several tools have been created for auditing clinical records; one such tool that may be used for any inpatient specialty is the CRABEL score system developed by CRAwford-BEresford-Lafferty. Aims This research aimed to evaluate the oral surgical records using the CRABEL scoring system for quality assessment. Materials and methods The case audit was performed from June 2023 to February 2024 for all Excisional biopsy cases of Oral Squamous Cell Carcinoma. Relevant data was retrieved from the Dental Information Archival Software (DIAS) of Saveetha Dental College and Hospitals, Chennai. It was evaluated by two independent oral pathologists trained in CRABEL scores. Two consecutive case records were evaluated. Fifty points were given for each case record. Scoring was given according to initial clerking (10 points), subsequent entries (30 points), consent (5 points), and discharge summary (5 points). The total score was calculated by subtracting the total deduction from 100 to give the final score. The mean scores of the case records were calculated. A descriptive statistical analysis was done with Statistical Package for Social Sciences (SPSS version 23.0; IBM Inc., Armonk, New York). Inter-observer agreement and reliability assessment were made using Kappa statistics. Results From the DIAS in that period, the data of 52 cases were retrieved and reviewed. There was no proof of a reference source in the audited records, and one deduction was made to the reference score in the initial clerking, and the effective score was 98 out of 100. The mean values of 52 case records were also 98 out of 100. The observed kappa score was 1.0. There was no inter-observer bias in the scoring criteria. Both observers also gave the same scoring. Conclusion Our study illustrates that oral surgery case records in our institution were found to be accurate, as they maintained 98% of the CRABEL score value. Frequent audit cycles will help in standardizing and maintaining the quality of oral surgery case records.
Keywords: administration; clinical audit; consent; crabel scores; discharge summary; initial clerking; oral surgery case notes; quality; quality improvement research; quality indicator.
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