Assessing and Enhancing Surgical Operative Notes in a Low-Income And Middle-Income Country Hospital: A Model for Sustainable Improvement

Abstract Operative notes from surgical procedures are essential components of patient treatment, acting as official records and facilitating communication between medical staff. However, inconsistencies in how these notes are recorded, especially in low- and middle-income countries, can jeopardize patient well-being and the smooth continuation of treatment. This research sought to assess and enhance the standard of surgical operative notes at the Ribat University Hospital, Sudan, by implementing targeted improvements. A two-part audit was conducted in the hospital's Department of Surgery to assess and improve the quality of operative notes. The first phase reviewed 100 past notes to establish a baseline, followed by the introduction of a standardized template based on RCSEng guidelines and staff training. The second phase evaluated 100 new notes to measure the impact of these interventions using a three-zone compliance indicator. Before the changes were made, significant gaps were identified in important areas of documentation, such as the expected amount of blood loss (33.3% documented), measures to prevent deep vein thrombosis (35% documented), and documentation of the complications that happened in the operation (25% documented). After the intervention, there were considerable enhancements, with adherence to documentation standards reaching 97 to 100% for several key aspects. The introduction of a standardized format for documentation and the provision of training for staff markedly improved the quality of surgical operative notes. To maintain these positive changes and further enhance patient care, ongoing audits and reinforcement of best practices are advised.