Beyond the Scalpel: Improving Operative Note Quality in Gabeet Specialized Hospital, Sudan

Background Operative notes are important medicolegal documents that guarantee patient safety and clinical handover, as well as support audit and research. Nevertheless, in most low- and middle-income countries, the quality of documentation is suboptimal even despite the official guidelines of the Royal College of Surgeons (RCS). This closed-loop audit aimed to evaluate and enhance the quality of the documentation of operative notes in Gabeet Specialized Hospital, Sudan. Methodology The proposed quality improvement project was a three-month study (May-July 2025). Two auditing cycles (n = 51) of operative notes were audited against RCS standards. After the initial cycle, interventions were performed, such as educating the staff, introducing standardized proformas, visual reminders, and increasing supervision. This formed the first part of the audit loop, followed by targeted changes and a planned re-audit. In the second cycle, documentation completeness was reevaluated, and compliance rates were compared, thereby completing the audit loop process. Results The mean compliance increased from 41.3% in the first cycle to 71.6% in the second (a 73% relative increase) against the RCS Good Surgical Practice (2025) standards. Significant gains were observed in the documentation of date, time, and type of operation (60.8% to 98%, p < 0.001); operative diagnosis and findings (55% to 84.3%, p < 0.001); and prophylaxis measures (39.2% to 90%, p < 0.001). Improvements were also seen for incision type and closure technique (51% to 75%, p = 0.01) and problems/complications (29.4% to 65%, p = 0.02). More modest changes were noted for tissue/prostheses details (25% to 39.2%, p = 0.05) and postoperative care instructions (20% to 29.4%, p = 0.08). Surgeon signature improved from 35% to 51% (p = 0.04). Conclusions Operational interventions improved compliance with documentation standards, but important gaps remain. Strengthening supervision, embedding regular audits, and adopting structured or electronic operative note systems are necessary to support sustained improvement and enhance patient safety.