Improving Pediatric Surgical Follow-Up Documentation: A Prospective Clinical Audit in the Department of Pediatric Surgery at National Ribat University Hospital, Sudan.

backgroundProper clinical documentation is essential for patient safety and the continuity of care, especially in pediatric surgery. In a resource-limited setting at Ribat University Teaching Hospital in Khartoum, Sudan (2021-2022), this study looked at how well the B-SOAP (short for Background, Subjective, Objective, Assessment, and Plan) follow-up documentation structure was followed. Baseline audits identified significant flaws, with a 21.9% (21 out of 96) adherence rate, highlighting systemic shortcomings in organized documentation standards. MATERIALS AND

methodsWe performed a prospective observational audit over three cycles (pre-intervention, intervention, and post-intervention), examining 68 B-SOAP sheets. Cause-and-effect diagrams and Pareto charts used in pre-intervention audits showed that the main problems were a lack of standard templates, poor training, and monitoring that wasn't consistent. Interventions comprised the revision of the B-SOAP template, the implementation of training sessions, and the establishment of audit feedback mechanisms. Compliance was evaluated by descriptive statistics, utilizing a 90% standard for completeness and correctness.

resultsPost-intervention compliance increased markedly to 90% (22 out of 24) (Δ+68.1%), exceeding objectives. The most significant improvement was seen in the Plan part, which went from 32.5% (seven out of 21) to 65% (14 out of 22). This was followed by the Subjective (21.2%, from four out of 21 to nine out of 22) and Assessment (21.0%, from two out of 21 to seven out of 22) parts. The documenting of objectives continued to be difficult (+16.4%), indicating ongoing obstacles to uniform data entry. Iterative audits and systematic feedback facilitated gradual improvements, consistent with evidence about the effectiveness of audits in resource-constrained environments.

conclusionStructured interventions, such as standardizing templates, training, and regular audits, greatly increased B-SOAP compliance, showing that it is possible to do so with paper-based systems. Despite problems with the infrastructure, the fact that 90% of the people who were supposed to follow the rules did so after the intervention shows how important it is to improve quality in a planned way. Maintaining progress necessitates continuous education, regular audits, and scalable digital solutions. This study gives a framework that can be used again and again to improve clinical documentation in similar settings with limited resources. This will immediately improve patient safety and care quality.