Evaluation and Improvement of the Quality of Surgical Operative Notes in the Department of General Surgery at Dongola Teaching Hospital, Sudan
Osama Elhadi Bakheet, Abubakr Muhammed, Ahmed Mohamed, Salih Ahmed Abdalla Ahmed, Abdalrahman Abdalhalim Abdalrahman Ali, Ahmed Salah Ahmed Sayed, Nada Hassan Farah Hassan, Mohammed Eltayeb Elnour Elawad, Mohammed Khalid Mohammedali Abdelrhman, Ayman Adil Eltayeb Abdelnour
Abstract
Background Surgical operative notes are essential for patient care and legal documentation. However, inconsistencies in the quality of these notes at Dongola Teaching Hospital, Sudan, highlighted the need for improvement. In line with guidelines from the Royal College of Surgeons of England (RCSEng), this study aimed to enhance the documentation practices in the hospital by implementing a standardized format. Methods A retrospective audit was conducted over three months at the General Surgery Department of Dongola Training Hospital. In the first audit cycle, 81 surgical notes were assessed, revealing significant deficiencies in adherence to RCSEng standards. An intervention was introduced, including a standardized template, training for surgeons, and widespread dissemination of the new format. A second audit cycle followed to assess improvements. Results In the first audit cycle, adherence to documentation standards was 50.3%, with missing or incomplete information in key areas. After the intervention, adherence improved to 71.9%. Notable improvements included documentation of extra procedures (18% to 100%), prosthesis details (0% to 100%), and antibiotic prophylaxis (71% to 97%). However, a slight decline was observed in postoperative care instructions, dropping from 100% to 90%. Conclusion The introduction of a standardized template and training significantly improved the quality of surgical documentation. Continuous efforts are necessary to maintain these improvements, particularly in areas where adherence remains suboptimal, such as postoperative care instructions.