Assessment of Clinical Documentation Quality in Orthopaedic Case Notes at Aminu Kano Teaching Hospital

High-quality clinical documentation in orthopaedic practice is essential for continuity of care, medicolegal protection, and health system data integrity. Inadequate documentation compromises patient safety and undermines clinical audit and research activities. This retrospective audit assesses the quality of clinical documentation in orthopaedic inpatient case notes at Aminu Kano Teaching Hospital (AKTH), North West Nigeria, over a three-month period. A random sample of 150 case files will be reviewed against a structured documentation quality checklist adapted from Royal College of Surgeons standards. Key elements assessed will include accuracy and completeness of admission clerking, consent documentation, operative notes, post-operative instructions, ward round entries, discharge summaries, and follow-up plans. A documentation quality score will be derived for each file, and associations with grade of doctor, specialty training year, and admission type will be analysed. The study hypothesises that operative note completeness and consent documentation are the most frequently deficient elements. Findings will be presented to the orthopaedic clinical audit committee at AKTH to guide targeted documentation training and introduce a standardised orthopaedic case note proforma. This research contributes to quality improvement evidence for orthopaedic documentation practices in North West Nigeria and supports the integration of documentation standards into professional development programmes. Keywords: clinical documentation, orthopaedic case notes, audit, Aminu Kano, documentation quality.