Introduction: Acute appendicitis is the most common surgical pain that requires surgical intervention in an emergency. Diagnosis of acute appendicitis is mainly a clinical judgment but many clinical scoring systems and advanced radiology is routinely used in developed countries. The aim is to reduce unnecessary removal of the normal appendix, which is still very high up to 37% in some parts of the world. Aim: The aim of this study was to assess the Negative appendectomy rate (NAR) in a tertiary care hospital of Quetta. Method: This is a prospective observational study carried out between November 2020 and June 2021.121 cases of acute appendicitis that underwent surgical management. Results: The study data revealed a negative appendectomy rate of 59.5% Tenderness rebound tenderness and total leucocyte count (TLC) showed statistical significance with histopathology findings. Females had a high negative rate of appendectomy. Conclusion: The study showed that on clinical judgment in the diagnosis of acute appendicitis will result in a high negative appendectomy rate, it is need of time to add radiology at least ultrasonography should be mandatory in every suspected case of appendicitis in our part of the world, and diagnostic laparoscopy in equivocal cases, especially in female patients.