From Audit to Action: Assessing and Implementing Improvements in the Operative Note Documentation for Day-Case Surgeries

Background Operative notes play an important role in ensuring patient safety, continuity of care, and medico-legal responsibility. Regardless of international standards, such as the Royal College of Surgeons (RCS) Good Surgical Practice, compliance is still low in most low- and middle-income countries, including Sudan. Aim The purpose of the closed-loop clinical audit is to assess and enhance adherence to the standards of operative note documentation in day-case surgeries at Almanagil Teaching Hospital, Almanagil, Sudan. Methods A quality improvement audit was performed over a period of three months, consisting of two cycles (pre- and post-intervention, with 53 operative notes each). A structured checklist was used to evaluate the documentation according to RCS standards. The interventions included staff education, standardized templates, and supervision. Chi-square tests were used to assess compliance between cycles. Results The compliance baseline was impaired in the main areas of estimated blood loss (0%), incision description (0%), deep vein thrombosis (DVT) prophylaxis (2%), and surgeon's signature (8%). The most substantial change following the intervention was that almost all parameters improved (p < 0.001), with 100% compliance achieved in operative findings, complications, closure technique, DVT prophylaxis, and surgeon's signature. There were continued inadequacies in the documentation of hospital file number (69.8%) and the reason why antibiotic prophylaxis was omitted (43.4%). Overall documentation increased by 41.3%, rising from 30.3% to 71.6% in Cycle 1 and Cycle 2, respectively. Conclusion The use of templates, education, and supervision as structured interventions made a significant contribution to enhancing the compliance of operative note documentation. Nevertheless, the lack of patient identifiers and the adequacy of the justification for antibiotic prophylaxis demonstrate that continuous audit cycles and e-documentation systems should be maintained to sustain the improvement.