Abstract
BACKGROUND AND AIM: Follow-up checklists are essential tools in ensuring comprehensive patient care, promoting clear communication among healthcare professionals, and enhancing patient safety. This two-cycle clinical audit aimed to evaluate and improve the quality of follow-up checklists in Rabak Teaching Hospital by assessing adherence to standardized documentation practices based on the National Institute for Health and Care Excellence (NICE) guidelines. METHODS: A retrospective and prospective observational study was conducted over two cycles, with 50 follow-up notes evaluated in each cycle. The first cycle (baseline) was conducted between June 10, 2024, and July 12, 2024, and the second cycle (re-audit) was conducted from August 13, 2024, to August 24, 2024. Data were collected using a premade questionnaire based on NICE guidelines and analyzed using quantitative and qualitative methods. RESULTS: The second cycle revealed significant improvements in the completeness and accuracy of follow-up documentation compared to the first cycle. Key areas such as patient history, vital signs, physical examination, and management plans showed enhanced adherence to guidelines. CONCLUSION: The findings demonstrate that structured follow-up checklists, combined with staff training and regular audits, can significantly improve documentation quality, thereby optimizing patient care. Continued re-auditing is recommended to sustain these improvements.