Abstract
Aim The aim is to audit the documentation process for trauma patients presenting to the surgical trauma department and to implement the WHO Standardized Emergency Unit Form: Trauma at Bashair Teaching Hospital in Khartoum, Sudan, in 2022. Methodology The audit was commenced by reviewing the documentation method for trauma patients. There was no standardized form in use. Current practice feedback was collected; then, the WHO Standardized Emergency Unit Form: Trauma was tested. The form was then implemented in one unit, where sessions for training on the proper use were conducted. Successively, generalization in all surgical units was achieved. From the hospital's records, comparisons were made between complications, mortality rates, duration of hospital stay, and mean time to initial assessment before and after execution. Results Case coverage was the primary indicator, describing the percentage of cases documented using the form per week. In the first cycle, the first week scored 31%, improving to 67% following that. The second cycle had 84-91% coverage throughout. The last cycle faced doctor strikes in the first week and the start of a new shift of foundation year trainees, achieving 53%, which was restored to 78% in the succeeding week. Furthermore, the mean time to initial assessment was significantly reduced by 31%, decreasing from 39 minutes±7.2 to 27 minutes±5.8 (p=0.023). Conclusion Medical documentation is crucial for patient care, ensuring continuity and addressing medico-legal issues. Implementation of the form improves communication between healthcare providers and ensures a systematic method to approach trauma patients, thereby warranting high-quality care.