Improving Pediatric Follow-Up Documentation Through a Structured Follow-Up Card: A Closed-Loop Quality Improvement...

Background Accurate and complete clinical documentation is essential for ensuring patient safety, continuity of care, and effective clinical decision-making. In many resource-limited settings, documentation practices remain inconsistent due to the absence of standardized tools, leading to gaps in care delivery. Objective This study aimed to evaluate and improve the completeness of pediatric follow-up documentation through the implementation of a structured follow-up card. Methods This was a closed-loop quality improvement project conducted at the pediatric outpatient department of Almanagil Teaching Hospital, Sudan. Two audit cycles were performed. The first cycle involved a retrospective review of 50 pediatric follow-up records over a two-week period in August 2025 to assess baseline documentation practices. Following this, a one-month intervention was implemented, introducing a structured pediatric follow-up card alongside brief staff orientation. The second cycle was conducted prospectively over two months (October-November 2025), including 50 follow-up records. Documentation completeness was assessed using predefined criteria, and comparisons between cycles were performed using the chi-square test, with a p-value <0.05 considered statistically significant. Results At baseline, documentation across all assessed variables was absent (0%). Following the intervention, significant improvements were observed across nearly all variables. Core documentation elements, including patient identification details, diagnosis, and treatment plan, reached 100% compliance (n = 50). Clinical variables such as chronic disease status and medication-related documentation improved to 74.0% (n = 37) and 68.0% (n = 34), respectively, while medication frequency and nutritional documentation exceeded 98.0% (n = 49). All improvements were statistically significant (p < 0.001), except for medical file number documentation, which remained unchanged. Conclusion The introduction of a structured pediatric follow-up card significantly improved documentation completeness. This study highlights the effectiveness of simple, low-cost interventions in addressing system-level documentation gaps and improving the quality of care in resource-limited settings.