Evaluating Improvement in the Documentation of Patient Progress Notes Through the BSOAP Framework: A Clinical Audit

Background Medical documentation is defined as the manual or electronic writing of health-related information of specific patients. It is a crucial process in patient care that ensures transparency, safety, and continuity of care. This audit aims to evaluate and improve the practice of progress notes documentation using the BSOAP (Background, Subjective, Objective, Assessment, Plan) framework. Methodology A retrospective-prospective, three-cycle clinical audit was conducted between March and November 2024 in the pediatric department at Dongola Specialized Hospital. A total of 511 morning follow-ups were evaluated. Intervention included local presentation after each cycle, small group discussion, visual reminders, and supervision. Results According to the component, the least documented was the plan. The least documented parameter was discussion and patient education, followed by new investigation requests and review of relevant systems. The most documented parameter was vital signs, followed by patient age. The second and third cycles showed improvement in all components, with higher improvement noted between the second and third cycles. All progress notes in the second and third cycles used a BSOAP-based approach. Conclusions Implementation of the BSOAP framework as a structured tool, combined with targeted training and supervision, led to notable improvement in documentation.