Introducing a Standardized Clinical Investigation Sheet for Medical Documentation at Dongola Specialized Hospital, Sudan: A Quality Improvement Project

Abstract

Inconsistent and incomplete documentation of investigation results at Dongola Specialized Hospital in Sudan has compromised patient safety and clinical efficiency. To address this, a two-cycle quality improvement project was conducted between April and May 2025, with targeted interventions implemented between the cycles to enhance compliance and address identified gaps. In the first cycle, root causes such as the absence of standardized forms, inadequate staff training, and a lack of accountability mechanisms were identified. Interventions included the introduction of a standardized investigation sheet, targeted staff education, and reinforcement strategies such as instructional posters and laminated samples. In the second cycle, redesigned forms with mandatory fields and visual cues were implemented, resulting in substantial improvements in documentation. Patient identification improved from 1.9% to 76.9%, critical markers such as blood group, hepatitis, and HIV status were consistently recorded (100%), and overall documentation completeness rose from 18.2% to 74.0%. However, persistent gaps remained in time-sensitive investigations such as arterial blood gases and glucose levels. These findings demonstrate that standardized documentation tools, supported by training and accountability, can significantly strengthen medical record quality and, by extension, enhance patient safety and clinical decision-making in resource-limited settings. Sustained monitoring, targeted refinements, and potential integration with electronic health records are recommended to maintain progress and scale improvements across similar contexts.