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Clinical notes are essential for patient care, guiding treatment decisions, and supporting research. This study explores how structured documentation impacts the quality of clinical notes in resource-limited settings like Sudan. This retrospective-prospective clinical audit was conducted in the Internal Medicine Department at Dongola Specialised Hospital. A checklist, developed using the National Institute for Health and Care Excellence (NICE) guidelines, assessed 10 key documentation areas, including patient history, vital signs, and management plans. Data from 50 randomly selected clinical notes were analyzed for each of two audit cycles: July 2024 (retrospective) and September 2024 (prospective, following the implementation of a structured template and staff training). Statistical analysis was employed to evaluate compliance improvements across cycles. Compliance improved significantly from 31.1% in the first cycle to 84.9% in the second. Specific improvements included chief complaint documentation (22% to 92%), current medications (18% to 86%), and lab results (12% to 86%). These findings highlight the positive impact of structured templates and targeted staff training on documentation quality. The study's findings are limited by its small sample size, which may not fully represent the broader patient population. Future research should address this limitation to validate and generalize the results. Implementing a standardized template and training improved the quality of medical documentation at Dongola Specialised Hospital.

Background Clinical audits serve as a critical tool for quality improvement, evaluating current practices to enhance patient care. Radiology request forms (RRFs) are essential for accurate diagnosis and treatment but often face challenges like incomplete or inaccurate information, illegibility, and non-compliance with established guidelines. This audit aimed to assess the adequacy of RRF completion at Othman Digna Teaching Hospital, Sudan, and implement interventions to improve compliance with guidelines. Materials and methods A prospective audit was conducted between November and December 2024. The first cycle involved assessing 50 randomly selected RRFs for adherence to the Royal College of Radiologists (RCR) guidelines. Interventions included introducing standardized forms and providing physician training. A second cycle of 50 RRFs was evaluated post-intervention. Data were analyzed using descriptive statistics and graphical representations. Results Compliance with eight key standards improved significantly post-intervention. Patient name compliance increased from 98% to 100%, while patient age rose from 12% to 98%. The inclusion of clinical background details and the question to be answered both reached 100% from initial rates of 16% and 4%, respectively. Overall mean compliance improved from 26% to 95.5%. Conclusions The study demonstrated significant improvements in the completion of RRFs following targeted interventions. Regular audits, standardized procedures, and continuous training are essential to sustaining compliance and improving communication between clinicians and radiologists, ultimately enhancing patient care.