Myuran Tharsika, Turner Oliver, Ben Doostdar Bijan, Lovett Bryony
Basildon and Thurrock University Hospital NHS Trust, United Kingdom.
BMJ Qual Improv Rep. 2017 Jan 16;6(1). doi: 10.1136/bmjquality.u211253.w4529. eCollection 2017.
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.
2001年设计了CRABEL评分，以便获得病历记录标准的数值评分。随着电子出院小结的出现，由于计算机能自动包含一些文档，CRABEL评分的许多组成部分现在已不再适用。CRABEL评分经过修改形成了电子CRABEL评分（e-CRABEL评分）。“出院小结中的患者详细信息”和“出院小结中的入院和出院日期”被“出院小结中的检查总结”和“药物图表上的静脉血栓栓塞症预防记录”所取代。新的e-CRABEL评分已在一个繁忙的外科病房用作每月的审核工具，以监测病历记录的长期标准，干预措施包括在科室审核会议上展示以及分两次为一组初级医生举办教学课程。在与利益相关者（初级医生、顾问和审核部门）进行讨论后，决定e-CRABEL工具足够简洁，可以每月完成。批评和干预措施包括在教学课程中使用照片示例、病例记录选择和对e-CRABEL标准的阐释。用于审核的工具需要更新，以便准确反映其测量的内容，因此对CRABEL评分进行了修改，形成了新的e-CRABEL评分。使用e-CRABEL评分初步收集和呈现的数据显示，在提高病历记录质量方面有前景。该工具足够简洁，可以每月进行，将标准维持在较高水平，还能提供静脉血栓栓塞症记录的数据。
