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Background: Medical records are essential documents that outline a patient's medical history and current health status. It involves maintaining records that include assessments of patient outcomes, care plans, and interventions necessary to meet patient needs. A patient's medical record encompasses details about their condition, as documented by healthcare professionals, including clinical assessments, evaluations, and professional opinions related to the delivery of care. Methods: This retrospective study aimed to evaluate the adequacy of our documentation for acute ankle fractures in accordance with the British Orthopaedic Association Standards for Trauma and Orthopaedics (BOAST) guidelines, encompassing a total of 41 cases. The research was conducted at the Gezira Center for Orthopedic Surgery and Traumatology (GCOST) in Wad Madani, Sudan, from May 12 to July 12, 2022. Results: Of the 41 recorded notes for acute ankle fractures, 26 (63.4%) were documented by medical officers and 15 (36.6%) by orthopaedic trainees. Most fractures (25 cases, 61%) occurred in individuals aged 18-40 years, and the gender distribution showed that males accounted for most fractures, with 29 cases (70.7%). Additionally, all patients (100%) had a documented cause of injury. Skin integrity was noted in 38 patients (92.7%). Vascular examination was documented in 18 patients (43.9%), while neurological examination was recorded in 16 patients (39%). Conclusion: Although the cause of ankle fractures was reported in all patients, the neurovascular examination was insufficiently documented, compromising patient care and failing to meet national standards, as highlighted in our study. We recommend implementing the BOAST guidelines to ensure proper documentation and essential assessments.
Mohamed et al. (Sat,) studied this question.