Enhancing Clinical Documentation: The Effect of Structured Templates on Follow-Up Notes in a Low-Resource Hospital...

Area of Science:

• Healthcare Informatics
• Clinical Documentation Improvement
• Global Health Equity

Background:

• Accurate clinical documentation is vital for patient care quality.
• Low-resource settings like Sudan often use unstructured documentation methods.
• This study assessed structured documentation's impact at Hasahesa Hospital.

Purpose of the Study:

• To evaluate the effectiveness of structured documentation practices.
• To improve the quality of clinical notes in a Sudanese hospital.
• To provide evidence for adopting structured documentation in similar settings.

Main Methods:

• A mixed retrospective and prospective audit design was used.
• Two cycles of record review (50 records each) were conducted.
• A checklist based on National Institute for Health and Care Excellence (NICE) guidelines assessed documentation quality.

Main Results:

• Overall documentation compliance increased from 38.2% to 87.2% (P < 0.001).
• Significant improvements were observed in documenting chief complaints, history of present illness, and medications.
• Laboratory results documentation saw the largest improvement, increasing by 75%.

Conclusions:

• Structured documentation significantly enhanced clinical note completeness and quality.
• Continued focus on history of present illness, past medical history, and medications is needed.
• Ongoing training and standardized templates are crucial for sustained improvement and optimized patient care.