Emergency Room Medical Record Modification to Optimize Patient Education at X Hospital

Authors

  • Engelbert Hariyanto Master Program in Hospital Management Faculty of Medicine Universitas Brawijaya Malang
  • Wening Prastowo Department of Forensic Medicine and Medicolegal Faculty of Medicine Universitas Brawijaya Malang
  • Lilik Zuhriyah Department of Public Health Sciences Preventive Medicine Faculty of Medicine Universitas Brawijaya Malang

DOI:

https://doi.org/10.21776/ub.jkb.2022.032.01.6s

Keywords:

Hospital management, lawsuits, medical records, patient education

Abstract

Regularly delivering information to patients and their families becomes a challenge for medical personnel in the Emergency Room (ER). Patients, or their families, often do not remember that education about their illness has been delivered. It can also happen because family members who took the patients into the emergency room differed from those who received the education. This situation can lead to misunderstandings, especially if there are legal problems in the future. This study aimed to find the priority problem in the hospital, the root of the problem, and solutions to optimize patient education in the ER. The methods used in the problem-finding were interviews, Focus Group Discussions (FGD), and USG (Urgency, Seriousness, and Growth) scoring. The solution selection method used FGD, fishbone analysis, 5-whys table, and CARL (Capability, Accessible, Readiness, and Leverage) scoring. The problem found was the lack of optimal patient education in the ER. The priority of the root of the problem found was no written documentation in the patient's medical record regarding providing education to patients or families. The chosen solution was to modify the ER medical record by including a checklist of educational points and a column for patients or families to sign. Further research is needed to prove the effectiveness of this medical record modification in optimizing education in the ER.

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Author Biography

  • Lilik Zuhriyah, Department of Public Health Sciences Preventive Medicine Faculty of Medicine Universitas Brawijaya Malang

    Public Health, Master Program in Hospital Management Faculty of medicine; Universitas Brawijaya

References

Purnomo M. Hubungan Kondisi Psikologis Penerima Persetujuan General Consent dengan Pemahaman tentang Hak Pasien Rumah Sakit Sesuai Undang-Undang Nomor 44 Tahun 2009 Pasal 32 di RS Aisyiyah Kudus Tahun 2016. Indonesia Jurnal Perawat. 2017; 2(1): 1–13.

Susanto DP, Pratama BS, and Hariyanto T. Analisis Faktor-faktor yang Mempengaruhi Pemahaman Pasien terhadap Informed Consent di Rumah Sakit. Jurnal Manajemen Kesehatan Indonesia. 2017; 5(2): 73–81.

Maniya OZ and McGreevy J. Managing Emergency Department Risk Through Communication and Documentation. Emergency Medicine Clinics of North America. 2020; 38(2): 267–281.

Gozdzialski A, Schlutow M, and Pittiglio L. Patient and Family Education in the Emergency Department: How Nurses Can Help. Journal of Emergency Nursing. 2012; 38(3): 293–295.

Fuenzalida C, Hernández G, Ferro I, Siches C, Ambrós À, and Coll-Vinent B. Long-Term Benefits of Education by Emergency Care Nurses at Discharge of Patients with Atrial Fibrillation. International Emergency Nursing. 2017; 35: 7–12.

Wirabrata IGM and Darma IMW. Tinjauan Yuridis Informed Consent dalam Perlindungan Hukum Bagi Pasien dan Dokter. Jurnal Analis Hukum. 2018; 1(2): 278–299.

Eko Yudhi Haryanto. Kedudukan Rekam Medis dalam Pembuktian Perkara Malpraktek di Bidang Kedokteran. Lex Crimen. 2015; IV(2): 151–159.

Swayden KJ, Anderson KK, Connelly LM, Moran JS, McMahon JK, and Arnold PM. Effect of Sitting Vs. Standing on Perception of Provider Time at Bedside: A Pilot Study. Patient Education and Counseling. 2012; 86(2): 166–171.

Hardjanti IW, Faramita NI, and Hartojo H. Pengembangan Jenjang Karir sebagai Strategi Mengelola Ketidakpuasan Kerja Perawat di Rumah Sakit. Jurnal Kedokteran Brawijaya. 2016; 29(3): 285–290.

Pradani EA, Lelonowati D, and Sujianto S. Keterlambatan Pengumpulan Berkas Verifikasi Klaim BPJS di RS X: Apa Akar Masalah dan Solusinya? Jurnal Medicoeticolegal dan Manajemen Rumah Sakit. 2017; 6(2): 112–121.

Iswari LPAP, Youandi AA, and Indriani W. The Causes of Lack of Pharmaceutical Logistics Monitoring in Surgery Rooms: A Case Study in a Type C Hospital Penyebab Kurangnya Monitoring Logistik Farmasi di Kamar Operasi: Studi Kasus pada Rumah Sakit Tipe C. Jurnal Kedokteran Brawijaya. 2020; 31(2): 121–125.

Judi J. Penerapan Informed Consent pada Pasien Gawat Darurat di Rumah Sakit Umum Daerah Ambarawa. Prosiding "Seminar Rekam Medis dan Manajemen Informasi Kesehatan" Tahun 2017. Semarang, 8 July 2017; p. 62–65.

Satiti YR, Susilo H, and Dewanto A. Penyampaian Informasi oleh Perawat dalam Persetujuan Tindakan Medis di Rumah Sakit: Permasalahan dan Solusi. Jurnal Kedokteran Brawijaya. 2015; 28(2): 169–173.

Kusumaningsih D and Sianturi A. Motivasi Internal Perawat terhadap Pelaksanaan Dokumentasi Edukasi Terintegrasi di Ruang Rawat Inap. Holistik Jurnal Kesehatan. 2020; 14(4): 529–535.

Ekmekci PE, Güner MD, Toman İN, et al. Does Content of Informed Consent Forms Make Surgeons Vulnerable to Lawsuits? Asian Journal of Surgery. 2020; 43(3): 497–503.

Coombs NM, Porter JE, and Beauchamp A. ED-HOME: Improving Educator Confidence and Patient Education in the Emergency Department. Australasian Emergency Nursing Journal. 2016; 19(3): 133–137.

Asthana V, Sundararajan M, Ackah RL, et al. Heart Failure Education in the Emergency Department Markedly Reduces Readmissions in Un- and Under-Insured Patients. American Journal of Emergency Medicine. 2018; 36(12): 2166–2171.

D'Souza RS, Johnson RL, Bettini L, Schulte PJ, and Burkle C. Room For Improvement: A Systematic Review and Meta-Analysis on the Informed Consent Process for Emergency Surgery. Mayo Clinic Proceedings. 2019; 94(9): 1786–1798.

Marco CA, LaFountain A, Thenappan A, and Ross DE. Consent for Emergency Treatment: Emergency Department Patient Recall and Understanding. The American Journal of Emergency Medicine. 2019; 37(7): 1387–1388.

Buller P, Miles S, and Wilcock M. A Checklist Approach to Support Safe Discharge – Work In Progress. Journal of Medicine Optimisation. 2018; 4(1): 13–18.

Doh J, Hencken L, Mlynarek L, and MacDonald N. Utilization of A Standardized Discharge Checklist to Improve the Transition of Care for Patients Receiving Parenteral Nutrition. Nutrition in Clinical Practice. 2021; 36(4): 877–883.

Drake K, McBride M, Bergin J, Vandeweerd H, and Higgins A. Ensuring Safe Discharge with a Standardized Checklist and Discharge Pause. Nursing. 2017; 47(8): 65–68.

Pratiwi ID and Setijaningsih RA. Analisis dan Perancangan Desain Formulir Edukasi Terintegrasi Pasien Rawat Inap di RSUD kota Semarang Tahun 2015. [Thesis]. Universitas Dian Nuswantoro, Semarang. 2015.

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Published

2022-10-19 — Updated on 2022-10-19

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