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

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Published

2022-10-19 — Updated on 2022-10-19

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