Assessment and Standardization of Follow-Up Notes Among Healthcare Providers in the Internal Medicine Unit at Mek Nimir Hospital: A Two-Cycle Clinical Audit From February to December 2025.

Complete follow-up notes support continuity of care by communicating the patient's current symptoms, objective findings, clinical assessment, and management plan. This clinical audit evaluated whether a standardized Background, Subjective, Objective, Assessment, and Plan (BSOAP) format could improve the completeness of inpatient follow-up documentation in the Internal Medicine Unit at Mek Nimir Hospital. A prospective before-and-after, two-cycle clinical audit was conducted using unpaired groups of inpatient follow-up notes. The baseline cycle reviewed 42 notes from February 10 to October 1, 2025. After introduction of a standardized BSOAP format, focused staff teaching, and feedback on documentation gaps, the re-audit reviewed 14 notes from December 1 to December 25, 2025. Each note was assessed for the five BSOAP domains and for complete documentation of all five domains. Two-sided Fisher's exact tests were used to compare proportions because the cycle samples were unpaired, unequal in size, and included small or zero cell counts. Subjective documentation increased from 0/42 (0.0%) at baseline to 14/14 (100.0%) at re-audit, Assessment documentation increased from 7/42 (16.7%) to 13/14 (92.9%), and complete BSOAP documentation increased from 0/42 (0.0%) to 11/14 (78.6%); all three changes were statistically significant (p<0.001). Objective and Plan documentation remained at 100.0% in both cycles. Background documentation decreased from 42/42 (100.0%) to 12/14 (85.7%), but the difference was not statistically significant (p=0.059). A structured BSOAP follow-up format supported by focused teaching and audit feedback was associated with substantial improvement in documentation completeness. Continued use of the format and repeated audit cycles are needed to sustain the improvement and address the remaining gaps in Background and Assessment documentation.