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All Journal Media Ilmu Kesehatan PELS (Procedia of Engineering and Life Science)
Wuryanto, Sis
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Computer Science & IT Control & Systems Engineering Electrical & Electronics Engineering Engineering Health Professions Medicine & Pharmacology Nursing Public Health

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TINJAUAN PELAKSANAAN PENGISIAN INFORMED CONSENT PADA KASUS BEDAH ORTHOPEDI DI RS PKU MUHAMADIYAH GAMPING SLEMAN YOGYAKARTA Wuryanto, Sis; Khodijah, Nurul
MEDIA ILMU KESEHATAN Vol 5 No 3 (2016): Media Ilmu Kesehatan
Publisher : Universitas Jenderal Achmad Yani Yogyakarta

Show Abstract | Download Original | Original Source | Check in Google Scholar | Full PDF (50.036 KB) | DOI: 10.30989/mik.v5i3.171

Abstract

Background: Physicians should provide clear information to the patients and/or their families before undertaking significant intrerventions. Informed consent sheets must be completed and signed as one of the legal aspects in medical practice. Based on a preliminary study conducted in June 2016 at RS PKU Muhamadiyah Gamping, the application of informed consent was incomprehensive. Objectives: To analyze the information supplied to the patients and identify factors inhibiting the implementation of informed consent in orthopedic surgery cases at RS PKU Muhamadiyah Gamping. Methods: This research was descriptive qualitative with cross sectional approach. Subjects consisted of one surgical nurse, two medical record officers, and one head of the medical record. The study employed purposive sampling on April-June year of 2016 informed consent sheets, comprised 57 of informed consent sheets. Result: Information that is often provided by the physicians to the patients included diagnosis, objectives, interventions, prognosis and complications. However, alternatif interventions and others were not completely informed to the patients. Barriers to implement complete and thorough informed consent was the physicians’ limited time and the low level of patients’ knowledge. Conclusion: Physicians had provided rigorous information on diagnosis, objectives, interventions, prognosis and complications, but less information on the alternatif interventions and others. The physicians’ time constraint and patients’ knowledge level had been two factors that inhibited the thorough use of informed consent.
The Role of Electronic Medical Records as a Professional Communication Tool for Caregivers at Nyi Ageng Serang Hospital: Peran Rekam Medis Elektronik sebagai Alat Komunikasi Profesional Pemberi Asuhan di RSUD Nyi Ageng Serang Nurdiyansyah, Andi Karisma; Wuryanto, Sis; Asgiani, Piping; Setiawan, Fendi
Procedia of Engineering and Life Science Vol. 7 (2025): Prosiding Seminar Nasional dan Rakernas PORMIKI X
Publisher : Universitas Muhammadiyah Sidoarjo

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.21070/pels.v7i0.2100

Abstract

To improve the quality and efficiency of health services in hospitals, there needs to be good communication from care professionals working at the service facility. Communication between care-giving professionals can be done by data communication through Electronic Medical Records (RME). RSUD Nyi Ageng Serang has implemented an outpatient RME to support patient care. However, the existing application has not been optimally utilised. The aim was to determine the role of RME as a communication tool between care professionals at Nyi Ageng Serang Hospital. The type of research used was descriptive qualitative research with a cross sectional design. This study used observation and focused group discussion (FGD) methods for data collection. The subject of this research is professional caregivers in outpatient installations while the object is RME. The data analysis technique used was qualitative data analysis technique starting with data reduction, data presentation, and continued with conclusion drawing. The role of electronic medical records in the implementation of interprofessional communication and collaboration is as a means of communication, especially where every finding and opinion of health professionals by care-giving professionals is poured and put together in electronic medical records, the findings of the medical history and actions given to patients and documented in writing or recorded. However, all of these provide benefits such as more complete RM content, business and communication efficiency, strategic benefits, and easy access to information. The completeness of patient data documentation in the RME at Nyi Ageng Serang Hospital can be improved through strengthening supporting regulations for documentation, training on the completeness of patient data filling for PPAs, adding features to check the completeness of documentation and designing a reward and punishment system for PPAs in terms of completeness of documentation in the RME. The addition of optional features to determine the diagnosis of disease by adding a list of disease diagnoses based on ICD-10 to the RME system database which makes writing a patient's medical diagnosis more concise and standardised and writing the main diagnosis is only written one diagnosis.
Co-Authors Khodijah, Nurul Nurdiyansyah, Andi Karisma Piping Asgiani Setiawan, Fendi