Improving Pediatric Surgical Follow-Up Documentation: A Prospective Clinical Audit in the Department of Pediatric...

Proper clinical documentation is essential for patient safety and the continuity of care, especially in pediatric surgery. In a resource-limited setting at Ribat University Teaching Hospital in Khartoum, Sudan (2021-2022), this study looked at how well the B-SOAP (short for Background, Subjective, Objective, Assessment, and Plan) follow-up documentation structure was followed. Baseline audits identified significant flaws, with a 21.9% (21 out of 96) adherence rate, highlighting systemic shortcomings in organized documentation standards.

We performed a prospective observational audit over three cycles (pre-intervention, intervention, and post-intervention), examining 68 B-SOAP sheets. Cause-and-effect diagrams and Pareto charts used in pre-intervention audits showed that the main problems were a lack of standard templates, poor training, and monitoring that wasn't consistent. Interventions comprised the revision of the B-SOAP template, the implementation of training sessions, and the establishment of audit feedback mechanisms. Compliance was evaluated by descriptive statistics, utilizing a 90% standard for completeness and correctness.

Post-intervention compliance increased markedly to 90% (22 out of 24) (Δ+68.1%), exceeding objectives. The most significant improvement was seen in the Plan part, which went from 32.5% (seven out of 21) to 65% (14 out of 22). This was followed by the Subjective (21.2%, from four out of 21 to nine out of 22) and Assessment (21.0%, from two out of 21 to seven out of 22) parts. The documenting of objectives continued to be difficult (+16.4%), indicating ongoing obstacles to uniform data entry. Iterative audits and systematic feedback facilitated gradual improvements, consistent with evidence about the effectiveness of audits in resource-constrained environments.

Structured interventions, such as standardizing templates, training, and regular audits, greatly increased B-SOAP compliance, showing that it is possible to do so with paper-based systems. Despite problems with the infrastructure, the fact that 90% of the people who were supposed to follow the rules did so after the intervention shows how important it is to improve quality in a planned way. Maintaining progress necessitates continuous education, regular audits, and scalable digital solutions. This study gives a framework that can be used again and again to improve clinical documentation in similar settings with limited resources. This will immediately improve patient safety and care quality.