The Implementation of a New Inpatient Admission Sheet in the Department of Pediatrics at the Atbara Teaching...

Background Inadequate medical record documentation poses significant risks to patient safety and care continuity. This study aimed to analyze a quality improvement project that involved the implementation of a standardized inpatient admission sheet in the Department of Pediatrics at Atbara Teaching Hospital, Sudan. The project sought to address critical gaps in documentation completeness and accuracy. Methods We assessed a one-year quality improvement project (July 2024-July 2025) involving three audit cycles with two intervening interventions comprising staff training, standardized documentation protocols, checklist prompts, and enhanced supervision. Completeness rates for 25 admission parameters were evaluated across 153 pediatric admission records (Cycle 1: n=53; Cycle 2: n=50; Cycle 3: n=50). Statistical analysis was performed using chi-square (χ²) or Fisher's exact tests with significance set at p<0.05. Results At baseline (Cycle 1), documentation deficiencies were profound, with 0% completion of data on gender, triage, family/past medical/social histories, and most physical examinations. Anthropometric measurements (e.g., height and mid-upper-arm circumference (MUAC) were documented in under 5%. Following the first intervention (Cycle 2), significant improvements occurred in gender documentation (0% to 34.0%; χ²=19.8, p<0.001), past medical history (0% to 68.0%; χ²=56.2, p<0.001), and cardiovascular examinations (7.5% to 68.0%; χ²=45.2, p<0.001). MUAC documentation increased to 20.0%. After the second intervention (Cycle 3), core demographic parameters, including name, age, gender, weight, and date, reached near-complete documentation (84.0% to 96.0%), and address and triage improved significantly. However, detailed clinical histories and system examinations regressed to 0% completion. Vital signs, allergy, and discharge status documentation remained absent across all cycles. Conclusions Implementation of standardized documentation tools combined with targeted training substantially enhanced key demographic and presenting complaint documentation in pediatric admissions. Nonetheless, sustaining comprehensive clinical history and physical examination recording remains challenging, necessitating ongoing reinforcement, simplification of documentation workflows, and potential integration of electronic solutions to ensure durable quality improvements.