Journal Article

Evaluating and Improving the Quality of Surgical Operative Notes at the Port Sudan Teaching Hospital

Ahmed Altyeb, Amir Alamin, Mohamed, Mustafa, Elzubier Suliman, Etigad Salahuddin, Sir Alkhatim Ali, Alaa Osman, Mohamed Abdalrahman, Mahmoud Ali, Hassan Abdelkarim, Mohamed Khalid, Noureldaim Ahmed, Khalid Ahmed, Abdeljalil Mohamed, Galaleldin Mohamed, Elamin Elnour, Mohey Aldien Ahmed, Widaa Mohamed, Awad Abdalla, Muhammed, Abubakr, Elssayed Osman, Fatima Aladdin, Abdelbagi, Alnazeer Y, Elbashir Hassan, Elbokhari Mohamed

2024

Overview

Background Thorough and standardized documentation of operative notes is essential for effective communication, patient safety, legal protection, and the continuity of care. However, in many hospitals in Sudan, surgeons often use non-standardized methods, resulting in inconsistent and incomplete records. This study evaluates the quality of operative notes at the Port Sudan Teaching Hospital using the Royal College of Surgeons of England (RCSEng) guidelines, aiming to improve compliance and documentation practices. Methods A clinical audit was conducted in two cycles at the General Surgery Department. The first cycle, a retrospective review of 50 surgical notes, was carried out over one week in July 2024. The second cycle conducted prospectively on another 50 notes throughout September 2024, involved the implementation of an improved proforma and staff training. Data were collected using a standardized checklist aligned with Royal College of Surgeons in Ireland (RCSI) guidelines, covering 18 documentation criteria. Results were analyzed using Microsoft Excel 2016 (Microsoft Corporation, Redmond, Washington, United States) to assess improvements in compliance. Results The compliance with documentation standards increased significantly from 51.9% in the first cycle to 82.1% in the second cycle. Notable improvements were observed in recording operative findings (17, 34%), complications (34, 68%), and deep vein thrombosis (DVT) prophylaxis (47, 94%). Despite the overall progress, modest improvements were noted in documenting the anesthetist's name (2.5, 5%) and the surgeon's signature (3, 6%). These findings underscore the positive impact of structured proformas and targeted staff training. Conclusion The implementation of standardized documentation tools and staff training significantly improved the quality of surgical operative notes at the Port Sudan Teaching Hospital. While notable progress was achieved, continued efforts, including digital solutions and regular audits, are needed to sustain these improvements and promote patient safety.

• Publisher: Springer Nature B.V,Cureus
• Subject: Accuracy / Antibiotics / Audits / Clinical outcomes / Compliance / Disease prevention / Documentation / General Surgery / Medical malpractice / Patient safety / Postoperative period / Prostheses / Sampling techniques / Surgeons / Surgery / Teaching hospitals / Thrombosis / Training