Assessing and Enhancing Surgical Operative Notes in a Low-Income And Middle-Income Country Hospital: A Model for Sustainable Improvement

Abstract

Background

Operative notes from surgical procedures are essential components of patient treatment, acting as official records and facilitating communication between medical staff. However, inconsistencies in how these notes are recorded, especially in low- and middle-income countries, can jeopardize patient well-being and the smooth continuation of treatment. This research sought to assess and enhance the standard of surgical operative notes at the Ribat University Hospital, Sudan, by implementing targeted improvements.

Materials and Methods

A two-part audit was conducted in the hospital's Department of Surgery to assess and improve the quality of operative notes. The first phase reviewed 100 past notes to establish a baseline, followed by the introduction of a standardized template based on RCSEng guidelines and staff training. The second phase evaluated 100 new notes to measure the impact of these interventions using a three-zone compliance indicator.

Results

Before the changes were made, significant gaps were identified in important areas of documentation, such as the expected amount of blood loss (33.3% documented), measures to prevent deep vein thrombosis (35% documented), and documentation of the complications that happened in the operation (25% documented). After the intervention, there were considerable enhancements, with adherence to documentation standards reaching 97 to 100% for several key aspects.

Conclusion

The introduction of a standardized format for documentation and the provision of training for staff markedly improved the quality of surgical operative notes. To maintain these positive changes and further enhance patient care, ongoing audits and reinforcement of best practices are advised.

Keywords

clinical audit - documentation quality - quality improvement - low- and middle-income countries - surgical operative notes

Data Availability Statement

All data generated or analyzed during this study were included in this published article. Although some data that support the findings of this study are available from [Ribat University Hospital authority], restrictions apply to the availability of these data, which were used under license for the current study, and so are not publicly available. Data are, however, available from the authors upon reasonable request and with permission of [RUH authority].

Ethical Approval

The ethical approval was obtained from the Institutional Review Board at Ribat University Hospital (approval: Au0207 RUH). Experimental protocols were approved by the Ribat University Hospital Authority Institutional Review Board and the study protocol were performed in accordance with the relevant guidelines applied at the hospital.

Patients' Consent

The data used in the study are anonymized and informed consents were obtained from the participants.

Authors' Contributions

E.B.Y.G. (first author) was involved in the study design, data acquisition, drafting of the article, critical revision, and final approval of the manuscript. L.M.S.M. (co-author) contributed to data acquisition and approved the final version of the manuscript. A.A.D. (co-author) also contributed to data acquisition and approved the final version of the manuscript. All authors have read and approved the final manuscript.

Publication History

Received: 07 August 2025

Accepted: 09 October 2025

Article published online:
07 November 2025

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