Muhammed Abubakr, Kanan Ahmed Abdalmahmoud Asadig, Alrawi Mohammad, Mohamed Elhassan Noreldayem Mohamed Elhassan Momin, Elsiddig Mohamed Mohamed Shamseldin, Ahmed Osman Mohamed Asma, Yousif Marwa, Hamrawi Nahla Widatalla Abdalla, Saadeldeen Suliman, Ali Maria Faisal Abdalwahab, Mansour Rania Yasser Babiker, Mohammed Ijlal Eltaiyb Ali, Nour Ahmed Mohamed Abdalrhman, Hamad Mohamednour Mohamed Kamalaldein, Eisa Manhal Eisa Galal, Elnour Mohey Aldien Ahmed Elamin, Hussein Afan, Elnisma Hana Barid, Sidahmed Yousra Goriesh AlNoor, Mohammed Altayeb Yousif Abdelgadir
Surgery, University of Gezira, Madani, SDN.
General Surgery, Managil Teaching Hospital, Managil, SDN.
Cureus. 2025 Aug 14;17(8):e90125. doi: 10.7759/cureus.90125. eCollection 2025 Aug.
Inadequate discharge documentation at Almanagil Teaching Hospital posed significant risks to patient safety and continuity of care, consistent with challenges seen in similar healthcare settings. The hospital aimed to address these gaps by enhancing the completeness, accuracy, and clarity of surgical discharge documentation through the development and implementation of a standardized discharge card, coupled with targeted staff training.
A prospective quality improvement project was conducted in two cycles (May-June 2025), involving audits of 44 (First Cycle) and 51 (Second Cycle) surgical discharge cards. Following baseline assessments, a structured discharge card was developed and implemented, along with targeted clinical staff training.
Post-intervention audits revealed substantial improvements. Documentation of telephone number and address rose from 0 (0%) to 47 (92.2%) and 49 (96.1%), respectively. The number of hospital file entries increased from 29 (65.9%) to 49 (96.1%). Referrers' names, roles, organizations, and contact details improved from less than three (6.8%) to 51 (100%). Clinical elements, such as documentation of intraoperative and postoperative complications, rose from nine (20.5%) and eight (18.2%) to 51 (100%). Overall compliance increased from 52.9% to 94.6%, marking a 41.7% gain.
The intervention significantly enhanced discharge documentation quality, reinforcing standardization, patient safety, and accountability. The model is scalable to similar resource-limited settings and warrants sustained auditing and ongoing training for long-term impact.
阿尔马纳吉尔教学医院出院文件记录不完善，给患者安全和护理连续性带来了重大风险，这与类似医疗环境中所面临的挑战一致。该医院旨在通过制定和实施标准化出院卡，并进行有针对性的员工培训，来提高手术出院文件记录的完整性、准确性和清晰度，以填补这些空白。
在两个周期（2025年5月至6月）内开展了一项前瞻性质量改进项目，对44份（第一周期）和51份（第二周期）手术出院卡进行审核。在基线评估之后，制定并实施了一份结构化出院卡，同时对临床工作人员进行了针对性培训。
干预后的审核显示有了显著改善。电话号码和地址的记录分别从0（0%）增至47（92.2%）和49（96.1%）。医院档案条目的数量从29（65.9%）增至49（96.1%）。转诊医生的姓名、职位、机构和联系方式从不超过三项（6.8%）增至51（100%）。术中及术后并发症记录等临床要素分别从9项（20.5%）和8项（18.2%）增至51项（100%）。总体合规率从52.9%增至94.6%，提高了41.7%。
该干预措施显著提高了出院文件记录质量，加强了标准化、患者安全和问责制。该模式可扩展至类似资源有限的环境，并且需要持续审核和持续培训以产生长期影响。
