Tinjauan Faktor Penyebab Ketidaklengkapan Pengisian Formulir Informed Consent di RSUD Dr. H. Moch Ansari Saleh Banjarmasin

2021 ◽  
Vol 6 (1) ◽  
pp. 91
Author(s):  
Eka Rahma Ningsih ◽  
Ravenalla S ◽  
Novia Lestiani ◽  
Aus Anhar ◽  
Mohammad Imam
Keyword(s):  
Informed Consent ◽  
Medical Record ◽  
Information Content ◽  
Medical Records ◽  
Legal Aspects ◽  
Consent Form ◽  
Patient Identification ◽  
Informed Consent Form ◽  
Descriptive Survey

ABSTRACTCompleteness of filling in the informed consent sheet in the medical record file is very important because it will affect the legal aspects of the medical record and the quality of the medical record so that in filling in the completeness of the data in the informed consent sheet it is necessary to carry out maximum implementation .. RSUD dr. H. Moch. Ansari Saleh Banjarmasin in 2012 showed that the level of incompleteness in the approval of medical treatment in the hospital room (surgery) was below 90% with the May period with a percentage of 46.7%. June with a percentage of 31.7% and 36.6%. The research objective was to determine the factors causing the incompleteness of filling out the informed consent form at RSUD DR. H. Moch Ansari Saleh Banjarmasin. Qualitative research method is descriptive survey. Respondents were 1 gynecologist, 1 head of medical records and 1 reporting officer for emdis records. Collecting data using interviews and observation of informed consent sheets. The results of the study identified the incomplete informed consent form by examining the patient identification component, the information content component, and the patient identification component. As well as identifying the availability of standard operating procedures (SOP) for approval of medical action. Based on the research results, it can be concluded that the informed consent form did not meet the national and standard filling standards in RSUDdr. H. Moch Ansari Saleh Banjarmasin because for the standard of completeness, the informed consent must be 100% complete. The filling of informed consent was not complete 100% in two components, namely the information content component (18.2% complete and 81.7% incomplete) and the patient's authentication component (90.7% completeness and 9.3% incomplete). The factor of incompleteness in filling out the informed consent based on the results of the research carried out was because the responsible doctor did not fill in the informed consent form again, both the content component and the patient authentication component) because he was busy providing services to other patients and there was no training related to filling the informed consent form. Keyword : informed consent, Factors Causing Incompleteness

Multicentric Clinical Audit of Chemotherapy Administration for Lymphoprolipherative Diseases in Day Hospital Patient Setting

Blood ◽  
2008 ◽  
Vol 112 (11) ◽  
pp. 4712-4712
Author(s):  
Giuliana Emilia Muti ◽  
Chiara Rusconi ◽  
Anna Brizio ◽  
Mauro Turrini ◽  
Piera Viero ◽  
...  
Keyword(s):  
Informed Consent ◽  
Dose Reduction ◽  
Medical Records ◽  
Clinical Audit ◽  
Treatment Plan ◽  
Consent Form ◽  
Expected Improvement ◽  
Care Process ◽  
Day Hospital ◽  
Informed Consent Form

Abstract Introduction Chemotherapy (CHT) administration is a high risk process. In particular, in the Day Hospital (DH) patient setting, the potential toxicity of medications is coupled with some organizational aspects, e.g. rapid patient turnover, multiprofessional involvement, lack of continuity of medical care, which can increase the risk of adverse events. The aim of this study was to evaluate the appropriateness of CHT administration for lymphoprolipherative disease in DH setting and the quality of medical charts, by using clinical audit. Audit is a quality improvement process that allows improvement of patient care and outcome through systematic review of care against explicit criteria and the implementation of change. The following evidence-based criteria were established for reviewing CHT administration: o CHT treatment plan (including histology, stage, goals of therapy, patient’s performance status, co-morbidities, CHT regimen) must be established prior to the initiation of CHT, and reported on medical record o CHT treatment summary (including number of cycles administered, extent of dose reduction and/or delay, reason for treatment delay or discontinuation, major toxicities or unexpected hospitalizations, biochemistry data) must be reported in medical records o Maintaining dose-density and dose-intensity may improve clinical outcome; the appropriate use of G-CSFs, in order to prevent neutropenia-related dose reduction or time delay, is particularly relevant when the intent of treatment is curative or to prolong survival o Inclusion of informed consent form in medical records is recommended, in order to verify the informative process and complete patient identification Patients and methods A random sample of 15% of all CHT courses administered for Lymphoma and Chronic Lymphocitic Leukemia from July 2006 to June 2007 in five Hematological DHs was analysed. A total of 282 courses were examined: 87 ABVD, 122 CHOP(R) and 73 FC(R). We collected data about patients, chemotherapy and medical charts. Patients’ clinical characteristics were similar between participating centres. Dose or time violations were considered significative if exceeding one day or 10% of scheduled timing or dosing, respectively. Results Results are reported in Table 1 and 2 Tab 1: courses with dose reduction or delay CHOP(R) (%) ABVD (%) FC(R) (%) Total (%) Dose reduction 30/122 (24,6) 9/87 (10,3) 5/73 (6,8) 44/282 (15,6) Delay 43/116 36/84 (42,9) 24/73 103/273 (37,7) Tab 2: causes of dose or time violation Dose reduction (%) Delay (%) Extra-hematological toxicity 14/44 (31,8) 6/103 (5,8) Neutropenia 3/44 (6,8) 27/103 (26,2) Infection - 17/103(16,5) Other clinical reasons (age, PS, comorbidity) 17/44 (38,7) 3/103 (2,9) Organizational causes - 25/103 (24,3) Not reported 10/44 (22,7) 25/103 (24,3) Pre-therapy biochemistry was available in 279/282 cycles (99%), while informed consent form was included in 131/282 (46.5%) medical charts. Post-therapy follow up revealed 4 unexpected hospitalizations. Conclusions Three main problems emerged: a lot of patients delayed treatment due to organizational causes (e.g. intermediate radiological restaging, holidays, lack of bed, biochemistry pending); in too many cases medical charts lacked causes of dose reduction (22,7%) or delay (24,3%); could guidelines driven use of G-CSF have prevented neutropenia-related delay? At the end of clinical audit, an action plan should be developed to improve the care process. In our study we induced and supported changes in the CHT administration process by various means: dissemination of educational material (as guidelines), interactive educational interventions, professional reminders, decision support. One year after a re-audit will be performed, in order to assess expected improvement.

scholarly journals THE MANAGEMENT OF MEDICAL REPORT COMPLETENESS FOR THE LEGALITY OF MEDICAL RECORD DOCUMENTS AT RSUD KRMT WONGSONEGORO (RSWN) SEMARANG CITY

2021 ◽  
Vol 20 (2) ◽  
Author(s):  
Suyoko Suyoko
Keyword(s):  
Informed Consent ◽  
Medical Record ◽  
Medical Records ◽  
Hospital Services ◽  
Human Element ◽  
Machine Element ◽  
Medical Disputes ◽  
Machine Elements ◽  
Medical Record Documentation

ABSTRACTBackground: Quality hospital services is reflected in the achieving of medical records. Improper medical record documentation would negatively affect the quality of service delivered to patients and it would disadvantage the hospital when medical disputes occur.Objective:Analyzing the management of medical record completeness at RSWN to guarantee the legality of medical record documents and its effect in supporting the completeness of medical record documents.Method:In this qualitative research,  observation and interviews were conducted to 60 PJRM officers in the Arimbi ward, Banowati, Nakula I and Prabukresna. The obtained data were qualitatively and quantitatively analyzed based on several underlying theories.Results:The results showed that the completeness of some aspects includinghuman, money, method, material and machine elements was proper. The quantitative analysis showed 100%, while the qualitative analysis showed a percentage of 100% with the exception on the informed consent component with the potential for loss of 99%.Conclusions:The human element required periodic outreach to PPA. In the machine element, special computerswere needed for PJRM officers, and the importance of informed consent for patients undergoing hemodialysis to obtain medical records with strong legal force. Key Words           :Management, Medical Record Completeness, Legality of Medical Records.

scholarly journals Penerapan Konsep Integrasi Berkas Rekam Medis di Rumah Sakit Umum Daerah Wates, Kulonprogo, Yogyakarta

2016 ◽  
Vol 1 (2) ◽  
pp. 264-277
Author(s):  
Savitri Citra Budi
Keyword(s):  
Informed Consent ◽  
Medical History ◽  
Medical Record ◽  
Medical Records ◽  
District Hospital ◽  
Discharge Summary ◽  
Ministry Of Health ◽  
Decentralized System ◽  
Informed Consent Form ◽  
District Hospitals

In Indonesia, under Law No. 44 of 2009 about Hospital, hospital has an obligation to organize medical records. Medical record is the file containing the notes and documents about the patient, examinations, treatments, actions, and other services that have been given to the patients (Regulation of Ministry of Health No. 269 of 2008 concerning Medical Record). Wates District Hospital has had a plan to change medical record storage from decentralized system to centralized one. One of the aims is obtained continuous patient’s medical history. Medical record must be prepared in such change. To implement the concept of integrated medical record by redesign of medical record forms in Wates District hospitals. The methods were carried out by following the design form concept, starting from collecting references, design, sources triangulation, first presentation, testing, revision, second presentasion, and the last was giving the design results to Wates District Hospital to be implemented. The application of the concept of integrated medical record was the new design of medical record forms consisting of a medical record folder, divider, emergency form, outpatient form, discharge summary form, resume form, inpatient approval form, informed consent form, and the newborn identification form. 

scholarly journals Pelaksanaan Informed Consent pada Pemeriksaan Intra Vena Pyelografi di Instalasi Radiologi Rumah Sakit Umum Sukoharjo

2017 ◽  
Vol 3 (1) ◽  
pp. 199-203
Author(s):  
Rini Indrati ◽  
Meita Shinta Fatikhatul Laila ◽  
Andrey Nino Kurniawan
Keyword(s):  
Qualitative Research ◽  
Informed Consent ◽  
Consent Form ◽  
Radiology Department ◽  
Medical Council ◽  
Patient Understanding ◽  
Informed Consent Form ◽  
Descriptive Qualitative

Background: The implementation of informed consent at Radiology department of Sukoharjo Hospital was conducted by administrative officer and radiographer. The officer explained the preparation of pyelographic intra-venous examination to the patient then the patient was asked to fill out and sign the informed consent form. According to the Indonesian Medical Council and Regulation of the Minister of Health of Indonesia, the delivery of informed consent is carried out by doctors. The doctor explains all the information contained in the contents of informed consent before taking any medical action. The purpose of this research is to know the implementation of informed consent done in the radiology department and patient understanding of the contents of the informed consent form.Methods: The type of this research is descriptive qualitative research with the observational approach. Data were collected in March-June 2017 by observational of informed consent and interviews of 30 patients who will conduct intra vena pyelographic examination. Data analyzed by descriptively.Results: The results showed that the provision of informed consent to intravenous pyelographic examination patient at Sukoharjo Hospital was performed by administration officer and radiographer before conducting the examination. The patient's understanding of the contents of informed consent has not been in accordance with the content of the informed consent form because the information submitted by the radiologist only concerning the preparation of intravenous examination of pyelography does not include examination procedures, objectives, risks, complications, diagnoses, prognoses, alternative other measures and risks, and costs.Conclusions: In radiology department of Sukoharjo hospital at Intravenapyelography patient informed consent delivered by administrative officers and radiographer. Patients understanding the content of informed consent

scholarly journals Aspek Hukum Rekam Medis atau Rekam Medis Elektronik sebagai Alat Bukti Dalam Transaksi Teurapetik

2017 ◽  
Vol 3 (2) ◽  
pp. 359-383 ◽  
Author(s):  
Sudjana Sudjana
Keyword(s):  
Medical Record ◽  
Electronic Medical Record ◽  
Medical Records ◽  
Health Workers ◽  
Legal Aspects ◽  
Literature Study ◽  
Descriptive Research ◽  
Positive Law ◽  
Approach Method ◽  
Administrative Sanctions

This study aims to obtain information on: first, the obligation to create and conceal Electronic Medical Record and its juridical consequences; Secondly, due to the law of absence or error in the manufacture of Electronic Medical Records and the position of Electronic Medical Record as a tool in the theoretical transactions.The research method used is normative juridical approach method, analytical descriptive research specification, research phase is done through literature study to examine primary law material, secondary law material, and tertiary law material. Data collection techniques are conducted through document studies, conducted by reviewing documents on positive law. Furthermore, the method of data analysis is done through normative qualitative.The results of the study indicate: Legal aspects of Medical Record or Electronic Medical Record   in Teurapetik Transactions related to: first, the obligation of health workers in coaching and health services to make Medical Record or Electronic Medical Record correctly and responsible for secrecy because it is the opening of Medical Record or Electronic Medical Record without With the permission of the patient having the consequences of criminal law. The absence or misuse of the Medical Record or Electronic Medical Record means that health workers may be subject to criminal, civil and administrative sanctions. Second, the position of  Medical Record or Electronic Medical Record is evidence in the form of a letter (if given outside the court), and expert information (if delivered in court).

scholarly journals A HOSPITALIZAÇÃO DO ADOLESCENTE NA ÓTICA DOS PROFISSIONAIS DE ENFERMAGEM

2018 ◽  
Vol 9 (2) ◽  
Author(s):  
Nathália Da Silva Pimentel Reis ◽  
Maria Fabiane Galdino Dos Santos ◽  
Inez Silva De Almeida ◽  
Helena Ferraz Gomes ◽  
Dayana Carvalho Leite ◽  
...  
Keyword(s):  
Intensive Care Unit ◽  
Intensive Care ◽  
Nursing Care ◽  
Medical Records ◽  
Rio De Janeiro ◽  
Descriptive Study ◽  
Tertiary Hospital ◽  
Legal Aspects ◽  
Quantitative Approach ◽  
Patient Identification

Objetivo: Compreender a ótica dos profissionais de enfermagem sobre a hospitalização de adolescentes. Metodologia: Pesquisa qualitativa, descritiva, utilizando entrevista com perguntas semi-estruturadas, realizada em uma enfermaria especializada em saúde do adolescente no Rio de Janeiro, no período de fevereiro a abril de 2016, com 15 profissionais de enfermagem. Resultados: A partir da análise de conteúdo de Bardin, definiram-se três categorias: a inexperiência no cuidado de enfermagem ao adolescente como um desafio, especificidades da adolescência, e sentimentos gerados pela hospitalização do adolescente no profissional de enfermagem. Conclusão: Conclui-se que os profissionais de enfermagem se colocaram inexperientes em cuidar desse público e declararam que o cuidado a essa população é um desafio para a equipe.Descritores: Adolescente, Enfermagem, Hospitalização.THE ADOLESCENT’S HOSPITALIZATION IN THE OPTICS OF NURSING PROFESSIONALSObjective: Analyze the contents of nursing notes in patients’ records in an intensive care unit (ICU) of a public tertiary hospital in Fortaleza, CE. It is a descriptive study with quantitative approach that analyzed 151 medical records of patients admitted to an ICU, from September 2014 to February 2015, whose 48 hour and discharge notes were evaluated. Data revealed notes with poor content, which did not express the patients’ situation, nor the nursing care provided. Data concerning date, time, and patient identification were adequate. However, the COREN number and the professional’s signature raised concern given the high percentage of non-compliance regarding ethical and legal aspects. Nursing notes did not reflect the severity of patients, nor the dynamics in the ICUDescriptors: Adolescent, Nursing, HospitalizationADOLESCENTE EN PERSPECTIVA DE LOS PROFESIONALES DE ENFERMERÍAComprender la óptico del profesional de enfermería de hospitalización de los adolescentes. Metodología: cualitativos, investigación descriptiva, utilizando entrevistas con preguntas semi-estructuradas en una sala especializada para la salud de los adolescentes en Río de Janeiro, en el período de febrero a abril 2016 con 15 profesionales de enfermería. Resultados: A partir del análisis de contenido de Bardin, definido tres categorías: la falta de experiencia en la atención de enfermería a la adolescente como un desafío, características de los adolescentes y los sentimientos generados por la hospitalización de los adolescentes en profesionales de enfermería. Conclusión: Se concluye que los profesionales de enfermería se colocaron inexpertos en cuidar de ese público y declararon que el cuidado a esa población es un desafío para el equipo.Descriptores: Adolescente, Enfermería, Hospitalización

Usability Testing

2001 ◽  
Vol 9 (2) ◽  
pp. 15-20
Author(s):  
Susan Waters ◽  
Melody Carswell ◽  
Eric Stephens ◽  
Ada Sue Selwit
Keyword(s):  
Informed Consent ◽  
Usability Testing ◽  
Consent Form ◽  
Research Project ◽  
Informed Consent Form ◽  
The Difference

How information is presented in an informed consent form can mean the difference between success and failure in a research project.

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