Improving Operative Note Documentation Through a Two-Cycle Clinical Audit at Sinnar Teaching Hospital, Sudan

IntroductionOperative notes are essential medical and medico-legal documents that support patient safety, postoperative management, and communication among healthcare professionals.However, compliance with recommended documentation standards frequently remains suboptimal.This study aimed to assess operative note documentation at Sinnar Teaching Hospital, Sinnar, Sudan, according to Royal College of Surgeons (RCS) guidelines and evaluate the impact of an educational intervention using a two-cycle closedloop clinical audit. MethodsA prospective, two-cycle clinical audit using total-coverage sampling was conducted in the Department of Surgery at Sinnar Teaching Hospital.A total of 500 operative notes were reviewed, including 250 notes in each audit cycle.The baseline audit was conducted between November and December 2022, followed by an educational intervention, while the re-audit was performed between July and August 2023.Data were collected using a structured checklist based on RCS guidelines.Evaluated parameters included administrative details, operative findings, technical surgical documentation, and perioperative safety measures.Descriptive statistics were used, and results were expressed as percentages. ResultsOverall compliance with RCS standards improved substantially from 43.8% in the baseline audit to 82.3% in the re-audit cycle.Major improvements were observed in administrative documentation, including recording of time (2% to 88%), date (14% to 97%), and elective versus emergency classification (0% to 96%).Documentation of surgical team members reached 100% compliance in the re-audit cycle.Technical operative documentation also improved, including operative procedure (40% to 84%), operative diagnosis (50% to 86%), and operative findings (74% to 90%).Safety-related documentation demonstrated improvement, with anticipated blood loss increasing from 8% to 72%, antibiotic prophylaxis from 0% to 50%, and deep vein thrombosis prophylaxis from 0% to 36%.Postoperative care instructions remained consistently high throughout both cycles (94% to 96%). ConclusionOperative note documentation at Sinnar Teaching Hospital was initially below recommended standards but improved markedly following an educational intervention.This study demonstrates that documentation quality is a modifiable aspect of surgical practice and can be significantly enhanced through structured audit-feedback and educational strategies, even in resource-limited settings.Ongoing re-audits, continuous professional education, and implementation of standardized documentation systems are recommended to sustain improvements and optimize patient safety and quality of surgical care.