Muhammed Abubakr, Modawy Alkheder Mohammed AlSiddig, Hamadelniel Alhadi Ibrahim Adil, Eltayeb Abdelnour Ayman Adil, Awad Mustafa Sabir Abakar, Eisa Asim, Mohamed Mahmoud Rayan Elmutaz, Mohammed Alkheir Seddig Alkazem, Ahmed Osman Mohammed Osman, Elnour Elawad Mohammed Eltayeb, Arbab Saeed Mie Sami, Hassan Himed Abdelrahman Abbas, AboAlella Mustafa A, Mohamed Abdullah, Elhag Adlan Tasneem Gadalla, Adam Ahmed Mogahid Hamdan, Ahmed Yousif Thana Siddig, Ahmed Bagar Shahad Elhadi, Adam Osman Areej Osman, Sailh Omer Mohammed Abd Elgaioum
Surgery, University of Gezira, Madani, SDN.
General Surgery, Rabak Teaching Hospital, Rabak, SDN.
Cureus. 2025 Apr 20;17(4):e82662. doi: 10.7759/cureus.82662. eCollection 2025 Apr.
Follow-up checklists are essential tools in ensuring comprehensive patient care, promoting clear communication among healthcare professionals, and enhancing patient safety. This two-cycle clinical audit aimed to evaluate and improve the quality of follow-up checklists in Rabak Teaching Hospital by assessing adherence to standardized documentation practices based on the National Institute for Health and Care Excellence (NICE) guidelines.
A retrospective and prospective observational study was conducted over two cycles, with 50 follow-up notes evaluated in each cycle. The first cycle (baseline) was conducted between June 10, 2024, and July 12, 2024, and the second cycle (re-audit) was conducted from August 13, 2024, to August 24, 2024. Data were collected using a premade questionnaire based on NICE guidelines and analyzed using quantitative and qualitative methods.
The second cycle revealed significant improvements in the completeness and accuracy of follow-up documentation compared to the first cycle. Key areas such as patient history, vital signs, physical examination, and management plans showed enhanced adherence to guidelines.
The findings demonstrate that structured follow-up checklists, combined with staff training and regular audits, can significantly improve documentation quality, thereby optimizing patient care. Continued re-auditing is recommended to sustain these improvements.
随访清单是确保全面的患者护理、促进医护人员之间清晰沟通以及提高患者安全的重要工具。这项两周期的临床审计旨在通过评估基于英国国家卫生与临床优化研究所（NICE）指南的标准化文档记录实践的依从性，来评估和提高拉巴克教学医院随访清单的质量。
在两个周期内进行了一项回顾性和前瞻性观察性研究，每个周期评估50份随访记录。第一个周期（基线）于2024年6月10日至2024年7月12日进行，第二个周期（重新审计）于2024年8月13日至2024年8月24日进行。使用基于NICE指南的预制问卷收集数据，并采用定量和定性方法进行分析。
与第一个周期相比，第二个周期显示随访文档记录的完整性和准确性有了显著提高。患者病史、生命体征、体格检查和管理计划等关键领域对指南的依从性有所增强。
研究结果表明，结构化的随访清单，结合员工培训和定期审计，可以显著提高文档记录质量，从而优化患者护理。建议持续进行重新审计以维持这些改进。
