Improving Emergency Department Documentation Through SAMPLE Tool Implementation: A Clinical Audit From Sudan

Abstract

Introduction: Efficient documentation is crucial for patient care in the high-pressure environment of the emergency department (ED), directly influencing clinical decision-making. Accurate documentation is vital for patient safety. The World Health Organization (WHO) and International Committee of the Red Cross (ICRC) recommend the SAMPLE tool (Signs and Symptoms, Allergies, Medications, Past Medical History, Last Oral Intake, Events leading to the incident) for quick history taking in emergencies. This audit aimed to assess compliance with the SAMPLE tool and improve history documentation practices among ED doctors. Methodology: This clinical audit was conducted at the Emergency Department of Ibrahim Malik Teaching Hospital in Khartoum, Sudan, from August 2022 to February 2023. It assessed medical officers' adherence to the SAMPLE tool and aimed to improve history documentation quality. Data were collected from patient files during two cycles, pre-and post-intervention, which included the introduction of new short-stay files. Results: The first audit cycle reviewed 352 short-stay patient files, revealing suboptimal documentation across all SAMPLE elements. The highest compliance was in documenting Signs and Symptoms at 68.2%. After the implementation of interventions, a second review of 230 files showed significant improvements in all elements, notably in documenting Signs and Symptoms (96.9%), Allergies (92.6%), and Medications (84.7%). Chi-square analysis confirmed that all improvements were statistically significant, with effect sizes ranging from moderate to strong. Conclusion: The introduction of new short-stay files and targeted educational sessions markedly improved the quality of patient history documentation in the ED. These findings highlight the potential of structured interventions to enhance clinical practice, thereby improving patient care and safety in emergency settings. Further clinical audits are required to ensure the sustainability of these improvements and to explore the long-term outcomes of such interventions.