Enhancing Clinical Documentation: The Effect of Structured Templates on Follow-Up Notes in a Low-Resource Hospital Setting.

BACKGROUND

Accurate and structured clinical documentation is essential for delivering high-quality patient care. While structured documentation tools have been increasingly adopted in well-resourced healthcare settings, many low-resource environments, such as Sudan, continue to rely predominantly on traditional, unstructured methods. This study aimed to evaluate the effectiveness of implementing structured documentation practices in improving the quality of clinical notes at Hasahesa Hospital.

METHODOLOGY

A mixed retrospective and prospective audit was conducted in two cycles at Hasahesa Hospital. The first cycle involved a retrospective review of 50 clinical records from July 2023, assessed using a standardized checklist developed based on National Institute for Health and Care Excellence (NICE) guidelines. Following a targeted training intervention, the second cycle prospectively evaluated another 50 clinical records from September 2023. Documentation quality was measured by compliance with ten key parameters. Data analysis was performed using Microsoft Excel, with compliance rates compared between the two cycles.

RESULTS

There were significant improvements in documentation quality following the intervention, with overall compliance increased from 38.2% to 87.2% ( < 0.001). Notable enhancements were seen in documentation of date and time (increased by 63%), chief complaints (60%), and history of present illness (45%). Documentation of current medications improved from 15% to 79%, while vital signs and physical examination recording increased by 18% and 40%, respectively. Documentation of laboratory results showed the greatest improvement, increasing by 75%. These results highlight the positive impact of structured documentation and targeted training on clinical record-keeping practices.

CONCLUSIONS

The introduction of structured documentation significantly improved the completeness and quality of follow-up clinical notes at Hasahesa Hospital. Despite these improvements, areas such as history of present illness, past medical history, and current medications require continued attention to achieve optimal compliance. These findings emphasize the necessity of ongoing staff training and the use of standardized templates to maintain and further enhance documentation standards, thereby optimizing patient care. Future audits should also explore expanding structured documentation practices across other hospital departments and settings.