Clinical Audit of Postoperative Documentation in the Kassala Teaching Hospital, Sudan: Compliance With Royal College of Surgeons of England Guidelines

Abstract

Background Accurate postoperative documentation is critical for patient safety, continuity of care, and medico-legal protection. This audit assessed postoperative documentation at the Kassala Teaching Hospital, Sudan and its compliance with the Royal College of Surgeons of England (RCS) guidelines, and evaluated the impact of targeted interventions. Methods A retrospective pre-intervention audit reviewed 44 postoperative notes from April to May 2025. A root cause analysis identified deficiencies (e.g., lack of awareness, no standardized templates, time constraints). Interventions included staff education, standardized templates, visual reminders, and enhanced supervision. A post-intervention audit of 51 notes evaluated improvements. Results Pre-intervention compliance was high for operative procedure (88.6%), findings (88.6%), and postoperative instructions (93.2%), but critically low for deep vein thrombosis (DVT) prophylaxis (25.0%), prosthesis identification (40.9%), and surgeon's signature (45.5%). Post-intervention, significant improvements occurred in operative diagnosis (from 45.5% to 86.4%; +89.8%) and date/time documentation (from 65.9% to 88.6%; +34.5%). However, DVT prophylaxis (27.3%), prosthesis identification (43.2%), and surgeon's signature (47.7%) remained suboptimal. Conclusion Targeted interventions significantly improved overall compliance with RCS documentation standards. Persistent gaps in documenting DVT prophylaxis, prostheses, and signatures highlight systemic challenges. Sustained improvement requires institutional changes (e.g., electronic templates, mandatory tracking systems, regular audits) and ongoing staff training. Re-auditing is recommended to ensure long-term adherence.