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

Surgical operative notes are vital for patient treatment, serving as essential legal records and key communication instruments for multidisciplinary medical teams. The Royal College of Surgeons of England (RCSEng) highlights the necessity of accurate, comprehensive, and timely recording of surgical interventions to maintain high standards of patient care and provide medicolegal security.[1] These records offer a detailed account of the surgery, aid in postsurgery care, and ensure seamless continuity of treatment across different health care professionals. Furthermore, they are indispensable for clinical reviews, efforts to improve quality, and for training purposes, thereby boosting patient safety and fostering professional advancement.[2]

Deficiencies in the documentation of surgical operative notes can create substantial legal and ethical problems. From a legal standpoint, insufficient records can lead to disagreements regarding the quality of care administered, potentially making health care providers vulnerable to accusations of malpractice. Ethically, incomplete notes jeopardize patient safety and the continuity of care because vital details might be absent, obstructing effective postsurgery management. Precise and detailed operative notes are crucial not only for medicolegal defense but also for maintaining ethical principles in patient treatment, highlighting the significance of this study's goal.[3] The standard of these records influences medical documentation and the flow of information vital for patient care. Beyond their medical importance, the quality of operative notes has financial and legal ramifications, making precise documentation essential for both audits and improving the delivery of patient care.[4] According to RCSEng recommendations, operative notes should be finalized immediately after the operation to prevent the omission of critical details and to preserve a distinct memory of the surgery. These notes need to be clearly and methodically written or dictated, encompassing details about the type of procedure, the surgeon's identity, information about assistants, surgical methods, and any complications or changes from the initial plan.[1] [4] [5] [6]

In many hospitals, particularly those with scarce resources, it is customary for surgeons to use plain, unstructured paper to document operative notes. This method often results in records that are inconsistent and lacking in detail. The absence of standardized formats frequently leads to the oversight of important information, which can adversely affect patient care and weaken the legal standing of medical records. The introduction of structured templates, as supported by the RCSEng, could significantly elevate the quality and consistency of surgical documentation in these settings. By embracing these templates, hospitals can make sure that all pertinent information is recorded systematically, thus enhancing both clinical results and the strength of medical records.[7]

Recent research has emphasized how standardized documentation contributes to better surgical results. For example, a study conducted at Dongola Teaching Hospital in Sudan revealed that adherence to documentation rose from 50.3 to 71.9% following the implementation of a standardized template and training for staff.[8] In a similar study, a clinical review at Doka Hospital reported a notable enhancement in the quality of documentation, with adherence increasing from 50.5 to 82.5% after a structured format and specific training sessions were introduced.[9] These results emphasize how effective structured measures are in improving practices for surgical documentation. Considering the vital function of operative notes in patient care and the proven advantages of standardized documentation, this research intends to assess and upgrade the quality of surgical operative notes at the Ribat University Hospital (RUH). By employing a structured methodology akin to those in earlier studies, the aim is to boost the precision, thoroughness, and uniformity of surgical documentation, ultimately leading to better patient outcomes and adherence to RCSEng guidelines.

Materials and Methods

Study Design and Setting

A clinical audit took place in the Department of Surgery at the RUH in Sudan, running from August 1, 2022 to March 1, 2023. The purpose of this audit was to assess the standard of surgical operative notes and to put measures in place to enhance how documentation is performed.

Audit Criteria and Definitions

The quality of surgical operative notes was evaluated through an audit that centered on three fundamental dimensions: precision, comprehensiveness, and uniformity. Precision was gauged by the degree to which the notes accurately represented the actual surgical event, encompassing correct details regarding instrumentation, intraoperative observations, and any adverse events. Comprehensiveness was appraised by confirming the inclusion of all requisite elements for thorough documentation, such as the preoperative diagnosis, operative discoveries, performed interventions, estimated blood loss, deep vein thrombosis (DVT) preventative measures, administration of prophylactic antibiotics, and directives for postoperative management. Uniformity referred to the consistent nature of documentation across various notes and practitioners, ensuring a systematic recording of all essential information.

Audit Population and Sample Size

This study involved a detailed review of 200 surgical records. Initially, a retrospective look at 100 notes was performed to set a benchmark for the quality of documentation before any changes were made. Subsequently, after introducing a new standardized documentation template and providing training to staff, another 100 notes were examined prospectively. This second phase aimed to evaluate enhancements in how thoroughly and correctly information was recorded. A simple random sampling technique was utilized to ensure the selection of notes was representative of the wide variety of surgical cases handled by the department, thus offering a dependable foundation for the audit. Notably, surgeons were kept uninformed about the monitoring of their documentation throughout both stages of the audit, a measure taken to reduce potential bias and capture typical clinical documentation habits.

Data Collection and Analysis

Trained medical professionals meticulously collected data by carefully reviewing surgical notes. They utilized a standardized checklist, based on RCSEng guidelines, which assessed 18 distinct criteria to gauge the completeness and accuracy of the recorded information.

The study began with an initial retrospective analysis of 100 randomly selected cases. Subsequently, a second phase involved a prospective review of another 100 cases. This second review occurred after implementing an updated documentation template (proforma) and conducting training sessions to educate staff on correct documentation procedures. These interventions aimed to improve the quality and uniformity of surgical records.

To evaluate the impact of these changes, the gathered data was systematically analyzed using Microsoft Excel 2016. A descriptive analysis was performed, employing a three-zone compliance indicator based on the scoring method detailed in [Box 1]. This analysis sought to identify and measure any enhancements in documentation quality between the study's two phases, thereby offering insights into the effectiveness of the revised proforma and training efforts.

Box 1 Details of the three-zone Indicators

The auditor utilized the subsequent scoring methodology when reviewing the record: 0 = If there is no sign that information was attempted to be documented. 1 = If insufficient information is documented. 2 = If some of the crucial details are documented. 3 = if the majority of the data are documented. 4 = if every detail of the information is documented. n/a = if the criteria are not relevant.

This meant that, if 150 patients were audited on each cycle, each standard may result in a score of 600. For instance, if they DVT prophylactic documented on all 150 patients, the compliance rate would be 100% and the overall score would be 600. If 120 patients have gotten their DVT prophylactic documented, the overall score would be 480, giving compliance of 80%. When n/a was inputted for a standard that did not apply to any of the patients, the spreadsheet automatically deducted 4 points from the projected result. Prior to converting the scores into compliance rates for the hospital, the scores for all procedures were obtained. The three-zone indication system assures that standard with an overall compliance of 80% or higher are high, those with an overall compliance of 50–79% are moderate, and those with an overall compliance of less than 50% are low.

Abbreviation: DVT, deep vein thrombosis.

Preintervention phase (first cycle) The study's first phase involved a retrospective examination of 100 randomly chosen surgical operative notes from the Department of Surgery.

Intervention phase To improve the identified shortcomings in documentation, a multifaceted intervention was put in place, consisting of the three main elements outlined below:

• Development of a standardized operation note format: A structured template, adhering to RCSEng guidelines, replaced the previous free-form documentation method.

• Distribution of the new template: The standardized template was shared across all surgical departments to ensure consistent documentation of operation notes.

• Education and training: Surgeons and surgical personnel were trained on the importance of thorough and standardized documentation. Training approaches included a Microsoft PowerPoint presentation during departmental meetings, focused group discussions, and individual sessions to highlight the proper application of the new template.

Postintervention phase (second cycle) after a 4-month intervention period, the next phase of the audit began. In this stage, 100 surgical operation records from the RUH were reviewed and assessed to determine the outcomes of the intervention. The goal was to evaluate improvements in the documentation process and adherence to RCSEng standards.

Results

This clinical audit involved an initial review of 100 operative records, with an additional 100 records examined in a subsequent phase. The study found a substantial enhancement in the quality of documentation across several important areas due to specific improvement efforts.

Initially, adherence to crucial documentation standards was inconsistent. For instance, recording of expected blood loss was recorded in (33%), DVT prevention measures were noted in only 35 case (35%), and administration of preventive antibiotics was documented for 41 cases (41%). Furthermore, documentation of any problems or complications occurred in 25 records (25%).

However, after implementing strategies to improve documentation, most notably the introduction of a standardized template aligned with RCSEng guidelines, the second phase showed considerable progress. While staff also received training, the standardized template was the main factor driving better completeness and accuracy in surgical notes. For example, documentation of anticipated blood loss surged from 33 to 74% (74 records), and recording of prophylactic antibiotic use went from 41% (41 records) to 85% (85 records. Significant improvements were also seen in the documentation of DVT prophylaxis, rising from 35 to 89% (89 records), and the recording of problems or complications, which climbed from 25 to 64% (64 records).

While some aspects, like the details of the operative procedure, saw a modest rise from 69 to 98% (29 records), and the details of closure technique saw a slight increase from 59 to 80% (80 records), the general trend in compliance clearly points to a significant improvement in the thoroughness of operative records (as shown in [Table 1]). Results for all standards were categorized into three-zone indicators and coded using the system outlined in [Box 1] for all cycles. [Table 2] displays the percentage of standards that fell into each level when the results were compiled for the RUH. This audit summary shows that compliance seems to be continuously improving. There are now fewer low standards and more high standards. These results underscore the success of the changes made, while also pinpointing areas that might require further attention to ensure consistently comprehensive documentation.

Table 1 Documentation in the first and second cycles, along with the corresponding percentage improvement

Documentation criteria	First cycle (N = 100), n (%)	Second cycle (N = 100), n (%)	Improvement (%)
Date	100 (100%)	100 (100%)	0%
Time	34 (34%)	90 (90%)	56%
Elective/emergency	3 (3%)	73 (73%)	70%
Name of operating surgeon	89 (89%)	100 (100%)	11%
Name of assistant	22 (22%)	86 (86%)	64%
Name of anesthesia personnel	5 (5%)	20 (20%)	15%
Operative procedure performed	69 (69%)	98 (98%)	29%
Incision	53 (53%)	74 (74%)	21%
Operative findings	47 (47%)	83 (83%)	36%
Any problems/complications	25 (25%)	64 (64%)	39%
Details of closure technique	59 (59%)	80 (80%)	21%
Anticipated blood loss	33 (33%)	74 (74%)	41%
Postoperative care instruction	100 (100%)	100 (100%)	0%
Antibiotic prophylaxis	41 (41%)	85 (85%)	44%
DVT prophylaxis	35 (35%)	89 (89%)	54%
Surgeon signature	17 (17%)	36 (36%)	19%

Abbreviation: DVT, deep vein thrombosis.

Table 2 Standards in each three-zone indicators

Indicator	Percentage of standards for August	Percentage of standards for March
High (80–100% compliance)	18.75 (3)	62.5 (10)
Moderate (50–79% compliance)	18.75 (3)	25 (4)
Low (<50% compliance)	62.5 (10)	12.5 (2)

Discussion

This audit's outcomes demonstrate considerable enhancements in the standard of surgical records at the RUH. These improvements followed the rollout of systematic changes, notably a standardized recording form and specific training for staff. The findings are consistent with other research in various health care environments, which also show that standardized documentation approaches boost the completeness and precision of operative notes.[10]

Before these interventions, significant gaps in documentation were evident. For instance, anticipated blood loss was never recorded (0%), DVT prevention measures were documented in 35% of cases, use of prophylactic antibiotics in 41%, and documentation of complication in 25%. Such omissions carry substantial clinical risks: failing to document blood loss can lead to unmanaged bleeding during or after surgery; missing records of DVT prophylaxis increase the danger of blood clots; incomplete antibiotic records raise the likelihood of infections at the surgical site; and inadequate postoperative guidance can result in poor patient recovery or mismanaged complications. These shortcomings highlight the critical role of precise documentation in maintaining patient safety, following clinical guidelines, and ensuring effective ongoing care. This underscores the study's importance in tackling these deficiencies to enhance both the quality of documentation and patient outcomes. These observations align with studies from other low-resource areas, where the absence of standardized templates frequently results in inconsistent and incomplete patient records.[8] [11] The introduction of a standardized template, based on RCSEng guidelines, combined with staff education, led to marked improvements in all measured areas. As an example, the recording rates for expected blood loss, use of preventative antibiotics, and after-surgery care instructions all rose to above 70% compliance after the intervention. Similar positive changes were seen in the documentation of DVT prophylaxis (82%), any problems or complications (73%), and additional procedures performed (94%).[9]

The effectiveness of these measures is mirrored in other studies. For example, research at Dongola Teaching Hospital in Sudan showed that adherence to documentation norms improved from 50.3 to 71.9% after a standardized template and staff training were introduced.[12] Likewise, a clinical review at Doka Hospital indicated a significant rise in documentation quality, with compliance jumping from 50.5 to 82.5% after implementing a structured format and focused training.[9] Such studies emphasize how effective structured interventions are in upgrading surgical documentation, particularly in settings with limited resources where nonstandardized recording methods are common.[10]

The progress noted in this audit also corresponds with results from studies in different regions. For instance, research at the Port Sudan Teaching Hospital reported a substantial increase in compliance with documentation standards, from 51.9% in an initial cycle to 82.1% in a subsequent cycle, following the use of an improved proforma and staff education.[8] Similarly, a study at Khyber Teaching Hospital in Pakistan found that applying RCSEng guidelines led to a distinct improvement in recording perioperative details, operative diagnoses, and team information, with adherence rates climbing from 70.8 to 95.7%.[6] These outcomes point to the widespread applicability of standardized documentation methods for enhancing the quality of surgical operative notes.[11]

Despite the overall advancements, some areas, like noting the anesthetist's name and the surgeon's signature, showed only limited improvement. This is in line with findings from other research, which have pointed out ongoing difficulties in documenting certain details, especially in environments where traditional recording habits are firmly established.[11] [13] For example, a study in Wad Madani, Sudan, revealed that the anesthetist's name was missing from all reviewed operative notes, indicating a systemic issue in documentation habits.[11] Overcoming these specific challenges might necessitate further targeted actions, such as incorporating electronic medical records (EMRs) and holding regular feedback meetings to emphasize the need for thorough documentation.[12]

This audit's results also highlight the need for regular reviews and ongoing quality improvement efforts to uphold high documentation standards. Research indicates that continuous audits and feedback systems are essential for maintaining improvements in documentation practices.[13] For instance, a study at the Arif Memorial Hospital in Lahore showed that regular audits and the introduction of a redesigned proforma resulted in a 35.7% improvement in operative note documentation.[13] Similarly, research at the Khyber Teaching Hospital demonstrated that introducing RCSEng guidelines and regular training sessions significantly boosted the quality of operative notes, with compliance rates increasing from 70.8 to 95.7%.[13]

In summary, the adoption of structured measures, such as standardized templates and staff training, has considerably enhanced the quality of surgical operative notes at the RUH. Nevertheless, ongoing work is necessary to tackle remaining challenges, especially in recording certain details and ensuring the long-term sustainability of these improvements. Future strategies should concentrate on integrating electronic documentation systems, performing regular audits, and offering continuous training to health care staff to ensure compliance with best practices in surgical documentation.[12]

The audit possesses limitations that could impact the breadth and transferability of its conclusions. First, its exclusive focus on a single hospital raises questions about the generalizability of the results to other health care institutions. Second, while the study primarily aimed to evaluate the impact of introducing a new proforma, it might not have accounted for other concurrent changes in clinical practices or shifts in patient outcomes that could have influenced the observed results. Third, the audit's strong reliance on quantitative data might lead to overlooking important qualitative aspects, such as the overall richness and detail of the clinical documentation. These constraints suggest that the findings should be interpreted cautiously and may not fully represent the wider context or subtleties of the documentation process.

Conclusion

The implementation of a standardized operative note template, combined with targeted staff training at the RUH, led to a notable enhancement in the quality and completeness of surgical documentation. Critical elements such as anticipated blood loss, the use of prophylactic antibiotics, and operative complication documentation demonstrated significant improvement after the intervention, reflecting a more structured and thorough approach to record-keeping. These results are consistent with existing evidence that highlights the benefits of standardized documentation systems in low-income settings. However, while the intervention yielded positive outcomes, some gaps in documentation quality persisted, underscoring the need for sustained efforts to maintain and build upon these gains. To ensure long-term adherence to best practices, it is recommended that the hospital implement biannual audits to monitor documentation quality and identify areas for improvement. Additionally, ongoing education programs, such as quarterly workshops and refresher training sessions, should be established to reinforce best practices and address emerging challenges. Exploring the integration of EMRs could further streamline documentation processes and reduce errors. Such measures will not only help solidify the improvements achieved but also contribute to enhancing patient safety and the overall quality of care delivered.

Conflict of Interest

None declared.

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.

• References

• 1 Good surgical practice: a guide to good practice. Royal College of Surgeons of England,; London, UK: 2014
• 2 Parwaiz H, Perera R, Creamer J, Macdonald H, Hunter I. Improving documentation in surgical operation notes. Br J Hosp Med (Lond) 2017; 78 (02) 104-107
• 3 Novitsky YW, Sing RF, Kercher KW, Griffo ML, Matthews BD, Heniford BT. Prospective, blinded evaluation of accuracy of operative reports dictated by surgical residents. Am Surg 2005; 71 (08) 627-631 , discussion 631–632
• 4 Johari A, Zaidi NH, Bokhari RF, Altaf A. Effectiveness of teaching operation notes to surgical residents. Saudi Surg J. 2013; 1: 8-12
• 5 Record your work clearly, accurately and legibly. 2017 . Accessed March 12, 2025 at: https://www.rcseng.ac.uk/standards-and-research/good-surgicalpractice/domain-3/#3.5
• 6 Nzenza TC, Manning T, Ngweso S. et al. Quality of handwritten surgical operative notes from surgical trainees: a noteworthy issue. ANZ J Surg 2019; 89 (03) 176-179
• 7 Alqudah M, Aloqaily M, Rabadi A. et al. The value of auditing surgical records in a tertiary hospital setting. Cureus 2022; 14 (01) e21066
• 8 Elhadi Bakheet O, Muhammed A, Mohamed A. et al. Evaluation and improvement of the quality of surgical operative notes in the Department of General Surgery at Dongola Teaching Hospital, Sudan. Cureus 2024; 16 (10) e70726
• 9 Hassan Ibrahim HM, Abdelrahman Zeineldeen AA, Mohamed Mohamed Alameen MA. et al. Enhancing surgical operative note standards at Doka Hospital, Sudan: a clinical audit. Cureus 2024; 16 (10) e72441
• 10 Abdelbagi AY, Muhammed A, Elamin Elnour MAA. et al. Evaluating and improving the quality of surgical operative notes at the Port Sudan Teaching Hospital. Cureus 2024; 16 (12) e75815
• 11 Mohamed A, Abdalla M. A study in Wad Madani, Sudan: are we documenting operation notes effectively?. Cureus 2024; 16 (08) e66544
• 12 Khalid A, Shahzad MZUA, Ahmed H, Gilani A, Khan KH. Audit of operative notes against Royal College of Surgeons guidelines in a tertiary health care surgical unit in Lahore. Cureus 2022; 14 (09) e29313
• 13 Toru HK, Aizaz M, Orakzai AA, Jan ZU, Khattak AA, Ahmad D. Improving the quality of general surgical operation notes according to the Royal College of Surgeons (RCS) guidelines: a closed-loop audit. Cureus 2023; 15 (11) e48147

Publication History

Received: 07 August 2025

Accepted: 09 October 2025

Article published online:
07 November 2025