An Audit of General Surgery Clinical Records (2021) in Ribat University Hospital, Sudan

Abstract

Background: Documentation is critical for effective patient management in hospitals, serving essential roles in improving patient care continuity, supporting clinical decisions, and fulfilling legal requirements. Comprehensive documentation not only aids in communication among healthcare providers but also serves as a vital record of patient history, facilitating accurate diagnosis and treatment. Clinical audits are systematic evaluations that compare current patient care practices against established criteria, helping identify deficiencies and promote adherence to quality standards. By increasing awareness of documentation practices, such audits can elevate the overall standard of clinical records, leading to improved patient care and safety. This is particularly important for healthcare professionals, as accurate records are essential for licensing and certification, as well as for demonstrating the delivery of quality care.

Purpose: This study aimed to conduct a medical audit of inpatient medical records in the General Surgery Department at Ribat University Hospital to assess the documentation quality and improve patient outcomes.

Methods: A cross-sectional study was performed on 518 long-stay medical records from Ribat University Hospital in 2021. A quantitative approach was used, employing a structured checklist of 26 points as the audit tool.

Results: Documentation was largely incomplete, with significant deficiencies identified: patient full name (17.6%), admission policy (21%), admission time (2%), treatment plan approval (2%), and discharge summary (4.4%). Better documentation was found for admission dates (86.3%), medical histories (81.5%), and diagnoses (87%).

Conclusion: Accurate and comprehensive medical record documentation is essential for quality care. This audit revealed major areas needing improvement in the General Surgery Department, emphasizing the need for initiatives to enhance documentation practices.

Keywords: checklist; documentation; files; medical audit; medical records.