Muhammed Abubakr, Awad Mustafa, Taha Mawada, Mohammed Ali Shorouq, Mohamed Alameen Moaid Abdallah, Musa Mohamed Zainab Hussein, Hamad Mohamednour Mohamed Kamalaldein, Mohamed Israa Isam, Ali Yousif Ahmed Shakir, Mubarak Abdullah Ola Atif, Mohamed Ali Muayad Mubarak, Suliman Mohamed Ashraf Mohamed, Mahadi Babiker Ahmed Yahia, Saeed Majzoub Abdalgader Omer, Sailh Omer Mohammed Abd Elgaioum, Ahmed Mohajer Abdulmonem Mohamed, Elsheikh Ahmed Mohammed Salaheldin, Fadalla Tagwa, Yousif Abdulhadi Shereen Abdelmoniem, Mohamed Mustafa
Surgery, University of Gezira, Madani, SDN.
Internal Medicine, Sudan Medical Specialization Board, Khartoum, SDN.
Cureus. 2025 Jul 24;17(7):e88685. doi: 10.7759/cureus.88685. eCollection 2025 Jul.
High-quality surgical operation notes are essential for patient safety, clinical communication, and medicolegal accountability. In low-resource settings like Sudan, inconsistent and incomplete documentation remains a challenge. This study aimed to evaluate and improve the quality of surgical operation notes at the Atbara Teaching Hospital using a closed-loop clinical audit.
A two-cycle audit was conducted using a standardized checklist based on the guidelines of the Royal College of Surgeons of England. Fifty surgical notes were reviewed in each cycle. Following the baseline assessment, interventions including the implementation of a structured proforma and staff education sessions were introduced. A re-audit was then performed to assess the impact of these measures.
Significant improvements were observed across most documentation parameters. Patient identification improved from 2% to 100% (p<0.0001), preoperative diagnosis from 8% to 93.5% (p<0.0001), and postoperative care instructions from 0% to 76.1% (p<0.0001). Documentation of anticipated blood loss, antibiotic prophylaxis, and closure techniques also showed statistically significant enhancements. However, gaps remained in areas, such as complication reporting and anesthetist details.
Structured interventions, including standardized templates and targeted training, substantially improved the completeness and quality of surgical operation notes. Ongoing audits, reinforced education, and potential integration of electronic records are recommended to sustain and build upon these improvements, particularly in resource-limited settings.
高质量的手术记录对于患者安全、临床沟通以及医疗法律责任至关重要。在苏丹等资源匮乏的地区，记录不一致和不完整仍是一项挑战。本研究旨在通过闭环临床审计评估并提高阿特巴拉教学医院手术记录的质量。
根据英国皇家外科医学院的指南，使用标准化检查表进行两轮审计。每个周期审查50份手术记录。在基线评估之后，引入了包括实施结构化表格和员工教育课程在内的干预措施。然后进行重新审计以评估这些措施的影响。
在大多数记录参数方面都观察到了显著改善。患者识别率从2%提高到100%（p<0.0001），术前诊断从8%提高到93.5%（p<0.0001），术后护理说明从0%提高到76.1%（p<0.0001）。预计失血量、抗生素预防和缝合技术的记录也显示出统计学上的显著提高。然而，在并发症报告和麻醉师详细信息等方面仍存在差距。
包括标准化模板和针对性培训在内的结构化干预措施显著提高了手术记录的完整性和质量。建议进行持续审计、加强教育以及潜在整合电子记录，以维持并进一步提升这些改进，特别是在资源有限的环境中。
