Background Comprehensive operation notes are essential for patient safety, continuity of care, and medico-legal documentation, particularly in orthopaedic surgery where procedural complexity and the use of implants place greater demands on accurate operative documentation. Despite established guidelines, incomplete surgical documentation remains a common problem, particularly in resource-limited settings. This clinical audit aimed to assess and improve the completeness of orthopaedic operation note documentation at Prince Osman Digna Referral Hospital, Sudan. Methods A two-cycle clinical audit was conducted over a one-year period (2024-2025). In the first cycle, 50 orthopaedic operation notes were retrospectively evaluated against 18 criteria derived from the Royal College of Surgeons (RCS) Good Surgical Practice guidelines. Targeted interventions, including staff education, dissemination of standards, and senior-led supervision, were implemented. A second prospective audit of 35 operation notes was conducted three months later using the same criteria. Results Baseline compliance was poor for several critical documentation elements, with 0/50 (0%) of operation notes recording anticipated blood loss, antibiotic prophylaxis, and deep vein thrombosis (DVT) prophylaxis. Operative findings were documented in 17/50 (34%) of cases, while details of tissue altered were recorded in 16/50 (32%). Following the intervention, measurable improvements were observed across most domains; these changes represent meaningful relative gains compared with baseline documentation performance: anticipated blood loss documentation increased to 10/35 (28.6%), antibiotic prophylaxis to 7/35 (20%), and DVT prophylaxis to 5/35 (14.3%). Core procedural elements demonstrated high compliance in the second cycle, including documentation of the surgeon's name in 35/35 (100%), procedure name in 34/35 (97.1%), and postoperative instructions in 33/35 (94.3%). Conclusion This two-cycle clinical audit demonstrated measurable improvements in orthopaedic operation note completeness following targeted educational and supervisory interventions, particularly in descriptive operative elements such as the surgical approach, operative findings, and documentation of the tissue altered. However, documentation of key patient safety parameters, including anticipated blood loss, antibiotic prophylaxis, and DVT prophylaxis, remained suboptimal despite improvement from baseline. These findings indicate that while awareness-based interventions can improve documentation quality, the implementation of a standardized, mandatory operation note template is likely required to achieve consistent and sustained improvements in patient safety critical documentation.
Ibrahim et al. (2026) studied this question.