Enhancing SOAP Documentation in Internal Medicine: A Three-Cycle Clinical Audit at Soba University Hospital

Abstract

High-quality clinical documentation, particularly using the SOAP (Subjective, Objective, Assessment, Plan) format, is essential for patient safety and effective healthcare delivery. In Sudan, inadequate documentation practices have been linked to poor continuity of care and increased risk of medical errors. This study aimed to evaluate and improve the quality of SOAP documentation in the Internal Medicine department at Soba University Hospital, Khartoum, through a structured clinical audit. Methods: A retrospective, three-cycle clinical audit was conducted using a locally adapted SOAP checklist covering 21 criteria across administrative, subjective, objective, assessment, and plan components. Data were collected from 111 patient records (37 per cycle) between March 2021 and March 2022. Following an initial audit identifying key deficiencies, targeted interventions-including educational seminars, consultant mentorship, standardized templates, and improved equipment provision-were implemented. Compliance rates were compared across audit cycles. Results: The initial audit revealed significant deficiencies, with only two criteria meeting the ≥80% compliance standard. Post intervention, notable improvements were observed in several areas: social history documentation increased by 48.4%, history of presenting illness by 25.7%, and medication planning reached the 80% standard. However, persistent gaps remained in administrative data, objective components, and allergy documentation. Differential diagnosis documentation showed variability across cycles. Conclusion: Targeted interventions led to measurable improvements in SOAP documentation quality, particularly in subjective and plan components. Nevertheless, administrative and objective documentation standards remain unmet, highlighting the need for sustained education, standardized processes, and systemic reforms. These findings provide a foundation for broader quality improvement initiatives in Sudanese healthcare settings.

Keywords: clinical audit; documentation; follow-up checklist; internal medicine; soap note.