Clinical audit of medical records based on clinical pathway: case study Benign Prostatic Hyperplasia (BPH)

Ida Sugiarti; Dedi Setiadi; Fadil Ahmad Junaedi; Ida Wahyuni

doi:10.34011/jmp2k.v36i1.3436

Authors

Ida Sugiarti Poltekkes Kemenkes Tasikmalaya, Tasikmalaya, Indonesia, Indonesia
Dedi Setiadi Poltekkes Kemenkes Tasikmalaya, Tasikmalaya, Indonesia, Indonesia
Fadil Ahmad Junaedi Universitas Bhakti Tunas Husada, Tasikmalaya, Indonesia, Indonesia
Ida Wahyuni Poltekkes Kemenkes Tasikmalaya, Tasikmalaya, Indonesia, Indonesia

DOI:

https://doi.org/10.34011/jmp2k.v36i1.3436

Keywords:

BPH, clinical audits, clinical pathways, medical records

Abstract

Background: Benign Prostatic Hyperplasia (BPH) is a common condition in adult men with a prevalence exceeding 50% by the age of ≥ 60 years. BPH causes symptoms of lower urinary tract infection, which reduces the quality of life and increases the burden of health services through visits, examinations, and medical interventions. BPH service practices still vary between health services, and medical records are still inconsistent and often deviate from clinical guidelines

Objective: To examine the implementation of the BPH clinical pathway (CP) through clinical audit and explore its inhibiting factors.

Methods: Qualitative research with a case study design in one regional referral service center. Data were collected through three triangulation sources: (1) observation of medical audits of 63 BPH patients' medical records, (2) in-depth interviews with 12 health workers (doctors and nurses), and (3) policy documents related to CP. Thematic analysis was carried out iteratively to identify patterns of CP non-conformity and implementation barriers.

Results: Thirty-five percent of medical records did not meet CP criteria. Key obstacles included low awareness of the CP among healthcare workers, limited clinical time, and lack of integration of health information systems.

Conclusion: The implementation of the BPH clinical pathway remains hindered by clinical and systemic factors. Evidence-based CP provides strategic solutions to improve service consistency and quality, but supporting policies, ongoing training, and integration of information systems are needed to optimize its application.

References

[1] A. Arifuddin, S. Rochmiyati, A. F. Nur, N. E. Dyastuti, H. Arifuddin, and Vidyanto, “Peranan Clinical Governance terhadap Penjaminan Mutu Rumah Sakit; Sistematik Review.pdf,” Heal. Tadulako J., vol. 8, no. 2, 2022, doi: https://doi.org/10.22487/htj.v8i2.530.

[2] F. Kanwal et al., “Clinical Care Pathway for the Risk Stratification and Management of Patients With Nonalcoholic Fatty Liver Disease,” Gastroenterology, vol. 161, no. 5, pp. 1657–1669, 2021.

[3] A. Fitria, A. Armani Sofa, T. Rochma Nurul, B. T. Purwaka, and W. J. Pudjirahardjo, “Penerapan Clinical Pathway sebagai Instrumen Pengendalian Biaya Pelayanan di Dr. Soetomo : Studi Penelitian Tindakan Penderita BPJS yang Menjalani Operasi Caesar dengan Sistem Pembayaran INA-CBG,” J. Keperawatan Silampari, vol. 4, no. 2, pp. 593–599, 2021, doi: https://doi.org/10.31539/jks.v4i2.1546.

[4] L. Noba, S. Rodgers, C. Chandler, A. Balfour, D. Hariharan, and V. S. Yip, “Enhanced Recovery After Surgery (ERAS) Reduces Hospital Costs and Improve Clinical Outcomes in Liver Surgery: a Systematic Review and Meta-Analysis,” J. Gastrointest. Surg., vol. 24, no. 4, pp. 918–932, 2020, doi: 10.1007/s11605-019-04499-0.

[5] R. Pinzon, L. Asanti, and K. R. Widyo SMF Saraf Bethesda Yogyakarta, “Clinical Pathway Dalam Pelayanan Stroke Akut: Apakah Pathway Memperbaiki Proses Pelayanan?,” J. Manaj. Pelayanan Kesehat., vol. 12, no. 1, pp. 20–23, 2009, doi: https://doi.org/10.22146/jmpk.v12i01.2562.

[6] T. Ebbers, R. P. Takes, L. E. Smeele, R. B. Kool, G. B. van den Broek, and R. Dirven, “The implementation of a multidisciplinary, electronic health record embedded care pathway to improve structured data recording and decrease electronic health record burden,” Int. J. Med. Inform., vol. 184, p. 105344, Apr. 2024, doi: 10.1016/J.IJMEDINF.2024.105344.

[7] M. Askari, J. L. Y. Y. Tam, and J. Klundert, “The effectiveness of clinical pathway software in inpatient settings: A systematic review.,” Int. J. Med. Inform., vol. 147, p. 104374, Mar. 2021, doi: 10.1016/j.ijmedinf.2020.104374.

[8] O. D. Paramita and I. Dwiprehasto, “Penggunaan Clinical Reminder Sebagai Instrumen Kendali Mutu dan Kendali Biaya Pada Penatalaksanaan Bayi Prematur Yang Dirawat di NICU RSUD Tarakan,” Universitas Gajah Mada, Yogyakarta, 2019.

[9] H. Djasri, “Pengantar Pelatihan Clinical Audit (Audit Klinik/Medik) di RS. Disampaikan pada Bimbingan Teknis Audit klinis (Audit Medis & keperawatan) di Rumah Sakit dan Puskesmas/Klinik, Yogyakarta, 29-30 November 2019,” 2019, Pusat Kebijakan dan Manajemen Kesehatan (PKMK) Universitas Gadjah Mada, Yogyakarta.

[10] D. R. Sari, “Audit Implementasi Clinical Pathway Diare Akut di Rumah Sakit Anak dan Bunda Harapan Kita Tahun 2016,” J. ARSI, vol. 3, no. 2, pp. 115–126, 2017, doi: http://dx.doi.org/10.7454/arsi.v3i2.2217.

[11] NHS, “Clinical Audit and Effectiveness Policy,” 2020.

[12] G. R. Hatta, “Pedoman Manajemen Informasi Kesehatan di Sarana Pelayanan Kesehatan,” in Pedoman Manajemen Informasi Kesehatan di Sarana Pelayanan Kesehatan, Jakarta: UI Press, 2022, p. 496.

[13] H. Djasri, “Corona Virus dan Manajemen Mutu Pelayanan Klinis di Rumah Sakit,” J. Hosp. Accredit., vol. 2, no. 1, pp. 1–2, 2020, doi: 10.35727/jha.v2i1.62.

[14] J. Walsh et al., “Path towards efficient paediatric formulation development based on partnering with clinical pharmacologists and clinicians, a conect4children expert group white paper,” Br. J. Clin. Pharmacol., vol. 88, no. 12, pp. 5034–5051, Dec. 2022, doi: 10.1111/BCP.14989.

[15] R. Cannarella, R. A. Condorelli, F. Barbagallo, S. La Vignera, and A. E. Calogero, “Endocrinology of the Aging Prostate: Current Concepts.,” Front. Endocrinol. (Lausanne)., vol. 12, p. 554078, 2021, doi: 10.3389/fendo.2021.554078.

[16] W. Zhang et al., “Depressive symptoms in individuals diagnosed with lower urinary tract symptoms suggestive of benign prostatic hyperplasia (LUTS/BPH) in middle-aged and older Chinese individuals: Results from the China Health and Retirement Longitudinal Study.,” J. Affect. Disord., vol. 296, pp. 660–666, Jan. 2022, doi: 10.1016/j.jad.2021.09.045.

[17] D. Porav-Hodade et al., “Prostate Dimensions and Their Impact on LUTS and Erectile Function: Is Length the Missing Link?,” J. Clin. Med., vol. 13, no. 23, p. 7123, Nov. 2024, doi: 10.3390/JCM13237123.

[18] C. ke Wang, J. hua Zhang, Y. Gao, X. yu Meng, H. xia Zhang, and H. huan Luo, “Quality of life and influencing factors in older adults with benign prostatic hyperplasia,” Int. J. Urol. Nurs., vol. 18, no. 1, p. e12391, Mar. 2024, doi: 10.1111/IJUN.12391.

[19] W. J. Tan and E. B. K. Kwek, “Outcomes after implementation of an open fracture clinical pathway.,” Arch. Orthop. Trauma Surg., vol. 140, no. 10, pp. 1373–1379, Oct. 2020, doi: 10.1007/s00402-020-03363-0.

[20] I. Sugiarti and F. A. Junaedi, “Pendampingan Pembuatan Clinical Pathway Dalam Peningkatan Mutu Pelayanan Kesehatan Di RSUD DR. Soekardjo Kota Tasikmalaya,” J. Pengabdi. Masy., vol. 3, no. 2, Jan. 2023.

[21] K. P. Freeman, J. R. Cook, and E. H. Hooijberg, “Standard operating procedures,” J. Am. Vet. Med. Assoc., vol. 258, no. 5, p. 477, 2021, doi: https://doi.org/10.2460/javma.258.5.477.

[22] T. Warashati, D; Novieastari, E; Afriani, “Optimalisasi Peran Dan Fungsi Kepala Ruangan Dalam Pelaksanaan Sosialisasi Regulasi Dan Standar Prosedur Operasional Keselamatan Pasien,” J. Keperawatan Komprehensif, vol. 6, no. 2, pp. 85–94, 2020, doi: https://doi.org/10.33755/jkk.v6i2.165.