Improving the Quality of Surgical Operative Notes at Managil Teaching Hospital, Sudan: A Clinical Audit

Accurate and comprehensive surgical operative notes are crucial for patient safety, continuity of care, and medico-legal purposes. However, inconsistencies in documentation quality at Managil Teaching Hospital, Sudan, prompted a clinical audit to evaluate adherence to international standards.

This study employed a retrospective-prospective clinical audit design conducted in the General Surgery Department at Managil Teaching Hospital. We evaluated a total of 101 operative notes (51 in the first, retrospective cycle from May 15 to June 15, 2025, and 50 in the second, prospective cycle from June 16, 2025, to July 16, 2025). Notes were assessed against 18 parameters derived from the Royal College of Surgeons of England (RCS) guidelines using a standardized checklist. Interventions included the introduction of a standardized operative note template, staff training sessions on best practices, and the display of visual aids in operating theaters. Data were systematically analyzed using Microsoft Excel 2016 (Microsoft Corp., Redmond, WA), employing descriptive statistics to compare compliance rates and calculate percentage improvements between cycles.

The audit revealed significant improvements in documentation quality following interventions. Notably, there were substantial gains in recording tissue details (from 25 (49%) to 42 (84%), an 35% improvement), prostheses (from 20 (39.2%) to 38 (76%), a 36.8% improvement), and postoperative instructions (from 40 (78.4%) to 45 (90%), an 11.6% improvement). The most significant improvements were observed in documenting complications (15 (29.4%) to 35 (70%), +40.6%) and extra procedures (10 (19.6%) to 30 (60%), +40.4%). However, some gaps persisted, particularly in recording anticipated blood loss (10 (19.6%) to 25 (50%)) and DVT prophylaxis (15 (29.4%) to 30 (60%)).

At Managil Teaching Hospital, the adoption of structured approaches like standardized templates, specialized training, and visual aids significantly boosted the caliber of surgical operative notes. Despite this considerable improvement, persistent vigilance, ongoing education, and consistent audits are crucial to tackle lingering weaknesses, particularly in documenting DVT prophylaxis and projected blood loss, thereby ensuring sustained enhancement in quality.