Background: Incomplete medical documentation threatens patient safety and efficiency. At Almanagil Teaching Hospital (Sudan), baseline audits revealed only 21% completeness of investigation forms. Aim: This study aimed to increase documentation completeness from 21% to ≥90% within six weeks through a standardized investigation sheet and staff training. Methods: A prospective observational quality improvement project (May-June 2025) applied two Plan-Do-Study-Act (PDSA) cycles. Cycle 1 audited 50 forms to assess baseline practice. Interventions included a redesigned standardized sheet, educational workshops, laminated samples, and posters. Cycle 2 audited 51 forms to assess improvement and gather feedback. Completeness was defined as the proportion of eligible fields documented. Two auditors independently reviewed 20% of forms (κ = 0.89). Because samples were independent, Pearson χ² and two-proportion z-tests were used, with Holm-Bonferroni correction for multiple comparisons. Effect sizes were reported with 95% confidence intervals. Run charts tracked weekly progress. Balancing measures included form completion time and laboratory turnaround. Results: Mean completeness increased from 21.7% (95% CI: 14.5-28.9) to 94.2% (95% CI: 91.1-97.3) (p < 0.001). Improvements were seen across patient identifiers (0-40% → 100%) and critical labs (12-14% → ≥98%). Median form completion time increased slightly (3.2 → 3.7 minutes; p = 0.12), with no change in laboratory turnaround (2.0 → 2.1 hours; p = 0.64). Staff feedback informed refinements, including urgent flags and color-coded fields. Conclusions: A standardized sheet with training and audit cycles significantly improved documentation completeness. Sustainability measures include weekly audits, documentation champions, rejection of incomplete forms, quarterly refresher training, and electronic medical record integration.
Muhammed et al. (Thu,) studied this question.