Journal Article

Evaluating and Improving the Quality of the Follow-Up Checklist at Dongola Specialised Hospital: A Clinical Audit

Mohamed, Mustafa, Abdelhay Mahmoud, Maithaa Elwlid, Fakher Aldeen Noman, Fakher Aldeen Raft, Hamid Mohammed, Moazer Ibrahim, Abdalla Ibrahim, Amal Ibrahim, Mohammed Hamed, Faris Jamalaldeen, Mohammed Ali, Mohammed Ali, Abdualhi Ali, Raeda Eshag, Fagier Mohamed, Ahmed Elfatih, Abdelhay Mahmoud, Mayada Elwalid, Abdallah Awadelkareem, Mohammed Maher, Muhammed, Abubakr, Awad, Ibrahim, Abdalgadir Hamdnaalla, Mohaned Altijani, Elawad Wedatalla, Mohamed Abdalla, Ali Gagar, Sara Mahmoud, Bakri Mohamed, Reham Abdalla, Noureldin Mustafa, Noureldin Mustafa

2024

Overview

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.

• Publisher: Springer Nature B.V,Cureus
• Subject: Audit cycles / Audits / Compliance / Data collection / Documentation / Efficiency / Electronic health records / Ethics / Hospitals / Illnesses / Internal Medicine / Medical history / Patient safety / Quality standards / Review boards / Sample size / Vital signs