Rut Herdianti Pramudyaswari Ekasiwi

12/338699/KU/15334
Tutorial Group 2
International Programme 2012

Report of Clinical Attachment

1. General Description
On Wednesday morning at June 19 th, 2013, group tutorial 2 of International Students batch 2012
visited a family physician clinic under responsibility of dr. Wahyudi Iswanto. The clinic established in
2001 as one of government public health helper. Later, in 2005 it was changed into a clinic with a
name of Klinik Dokter Keluarga Koperasi Masyarakat (The Family Doctor of Societys Cooperation).
The clinic is located near Bulaksumur area at Jl. Agro 38C. Since it is located on the side road, it is
easy for people from anywhere to come to the clinic. There were some
patients who lived at Condong Catur area, or even further than that, come
regularly because they feel comfortable on that physician family clinic.
Some people who come to visit for the first time knew the clinic only via
mouth-to-mouth news. They said that it was not hard to find this clinic
even if the direction given was not clear enough.
Aside from easy-to-access location, this clinic has enough spaces for
the patients to be relax and comfortable. More than 5 benches available;
approximately around 25 people can seat if all of the benches were fully
occupied. The atmosphere is bright due to many windows available. The
presence of windows allow good ventilation to occur to prevent patients in
waiting suffer from sultry weather. The white tiles of the floor give a simple
and clean impression towards anyone who just enters the clinic. Patients
are provided with some entertainment such as television and magazines
Figure 1: Magazines that
to stop boredom. For little kids under 2 years old, there are some areas
specially designed for them. There were ridden toys available so that the children would not be
annoyed for waiting so long.
Klinik Dokter Keluarga Koperasi Masyarakat services starts from
08.00
until 12.00 from Monday to Saturday. The number of patients come is
usually variable; ranging from 30 to 50 people a day. The peak days of
the
clinic is the day after a holiday, either Monday or days after public
holiday. The patients age are ranging from 3 months babies
to elder people. Thus, this clinic tries to offer variable
services to cover all the patients problems and needs.
There are 6 different rooms for different unit. Those rooms
are Prolanis (Chronic problems) room, General Practitioner
room, Dentist room, KIA (Khusus Ibu dan Anak Mother and
child) room, Tindakan (procedural) room, and Pharmacy
and Nutritionist room. Three air conditioners were placed in
Figure 2: Childrens area
the middle of the wall between two rooms. In that way,
the clinic could conserve electricity and yet providing
better ventilation and cooler condition at the same
time. General practitioner and Chronic Problems
service available every day whilst Dentistry is only
available at Tuesday, Thursday, and Saturday.
Nutritionist and a nurse accounts in procedural
rooms only available on Tuesday.
One lavatory is available inside. The restroom is
quite wide with large basin for water reservoir. There is
also a washing stand close to the lavatory. So, people
or patients may wash their hands after they went out
Figure 3: Facilities provided
from the lavatory. Many health posters are posted on the wall of
the clinic. The posters mainly discuss about infectious and dangerous diseases such as dengue and
HIV-AIDS with their prevention. Some posters also show the importance of washing hands for the
doctors and patients. They also had six steps of washing hands pasted on the wall close to the
chronic disease rooms. Those posters were completed by full pictures and simple language that is
communicable to common people who did not study medicine. Thus, the posters help simply to
educate and enhance patients knowledge indirectly.

2. Specific Observation
Klinik Dokter Keluarga Koperasi Masyarakat has two different
kinds of patients: the patients with ASKES (Asuransi Kesehatan
Health Insurance from Government) and the local patients. The
patients who have Health Insurance have their online and written
medical records saved in the clinic. The term of "local patients"
means that they are regular patients who come and do not have
the Health Insurance card. The local patient Medical record only
saved in written files. This differentiation is important on
determining the medicine given to the patients. For the local
patients' medication, they will be given mostly generic medicine
whereas Health Insurance card-holder can get the patent medicine
Figure 4: The Medical Records
Bank
subsidized by Indonesian government. The twist is that the
medicine for both local and Health Insurance card-holder is given for free. It is
already included in their registration fee from the first place.
To determine the price of persons registration, the register must see the
Kartu Tanda Pengenal (Identity Card) of him or her. There are two categories
based on address in the Identity Card. People inside Sleman area will be
subsidized by Univesitas Gadjah Mada (Gadjah Mada University) and thus
only paying for Rp5000,-. However, people who live outside of Sleman will be
charged with Rp17.000, - each person the difference very significant indeed.
Nevertheless, it is counted as affordable to society because it is cheaper than
any of private or public hospitals. Even though the practitioners are not paid,
some of procedural medications have different charges. For example, if people
register to go to the Consultant, they must pay for Rp20.000,-. Any laboratory
procedures will be charged from and above of Rp15.000,-. Special for any
procedure in dentistry, the prices must be lowered than in hospitals but higher
Figure 5: Registration
than clinic standard.
When a new patient registers, aside from showing his or her Identity card and Health Insurance
card or ASKES, the person will be asked to fill a form. That form will be used for his or her Medical
Record of the patient. The Medical Record of each patient is always filed in a stock map and saved
inside the administration room. All medical records are confidential; that means Medical Record is
patients and could not be taken or photocopy by another group of people accept the patients
themselves. Similar to the categories of patients, the Medical Record form is differentiated for people
with ASKES and the local people. The general format of both types of Medical Report is Full Name,
Complete Address, and Birth date, Blood Type, Parents Identity, Marital Status, Patients Job,
Patients Medication History and Contact Person for emergency case. The difference is that the
Medical Record form for ASKES card-holder provides more complete information about the patients.
The addition columns including Health Insurance Card number, the lists of Allergy, and the Lifestyle of
the patients.
After completing registration and payment processes, patients will have their vital signs taken. The
vital sign results will be written on patients health history inside the Medical Record stock map. Then
the patients will in turn wait to be examined by the doctors. The duration of each patient with the
doctor is ranging from five to fifteen
minutes. Common cases such as
influenza, fever, or coughing only takes
five to six minutes of consultation,
physical examination and patients
education whereas chronic problems
such as diabetes mellitus or heart
diseases take longer time until fifteen
minutes.
Before one patient enters the room,
the medical doctors are provided with
alcohol. They will always wash their
hands based on six steps hand washing
according to World Health Organization
Standards. Then, they will greet the
patients and ask them how they feel
about their illness. With high fluency and
Figure 6: The Medical Report Format for Local (left) and ASKES holder (right)
eloquently, the doctors ask the details of

sign and symptoms without thinking as if they are involved in conversation. For some patients that are
not actively engaged in conversation, the doctors tend to ask more questions to lead them. However,
doctors also tend to stop the conversation if they already have a diagnosis in mind. When educate the
patients, they usually educate while writing the prescription and/or the result of physical examination
to safe time. Hence, the doctors are trained to do efficient way of talking.
In the physical examination of the patients, not all techniques and steps are done as the theories
say. In fact, the doctors only do short percussion and palpation most of the time because they had
already predicted the treatment or the illness in mind. Hence, the physical examination did not take
long time, mostly only around two minutes. Besides, the vital sign is taken outside of the doctors room
and therefore the doctors only need to analyse the result only.
3. Discussion
According World Health Organization (WHO), a medical record is a written collection of information
about patients health and treatment1. Since it contains all informations regarding patients health
development, it is very essential to keep an eye on it. Therefore, it is correct the the clinic would not
allow anybody even a doctor to bring the Medical Record out from the clinic WITHOUT patients
informed consent. Due to technology development, electronic medical record is available too.
Nevertheless, the clinic use written Medical Reportas a main source of files. The online medical record
only provided for the Health Insurance card-holder because of the government rule. The online
medical record is admitted as efficient and effective by the clinics staff because patients health
condition could be accessed by any hospitals in Jogja. According to administration and pharmacy
staff, there has been an intention to convert all of written medical records to electronical data. WHO
itself agree that this will be a huge steps for any countries and should not focus on just going
paperless2. Although it is expected to be efficient, accurate, and environment-friendly, a system
should be thought to enable EVERY patients examination results whether it was a vital sign,
physical examination or laboratory tests can be managed inside the electronic medical record. So,
the electronic medical record form should be more completed compares to the written medical record
that available nowadays to ensure complete information about the patient.
Before every physical examination of a patient, the doctors always wash their hands using alcohol.
Some patients may notice and some may not. There are evenn posters telling about how important to
wash hand is. Unfortunately, some patients that walked out from the lavatory did not continue their
activities to wash their hands on the hand washing stand. This is due to patients oly KNOW handwashing is important without being
encouraged to do so. Hands are often in
contact to many things and hence, can be
one of disease media to spread. The
education of clinic staffs and doctors toward
patients is very important so that they
understand why they must always wash
their hands if possible.
To provide the best quality of services
and medicine is every healthcares vision.
Nevertheless, this vision is sometimes not
applied in how a clinic keep their medicine.
The clinic under dr. Wahyudi Iswantos
supervision works with government to obtain
Figure 7: Posters on Hand-Washings
stocks of medicine. There is an agreement
between the Public Health Division and the
clinic to take back the medicine if it is expired. So, the clinic itself does not throw away the medicine by
its own but keep the medicine disposal in a reserved manner. Some of the medicines are kept in a
bottles in big amount for instances 200 tablets inside the bottles. The pharmacy men will give the
medicine in a plastic only and taken with unclean plastic spoon. Sometimes, the lid of the bottles were
removed so that when the medicine is needed, the pharmacy men will take it directly with the spoon.
Even though, we cannot be hygienist all the time, it is essential to give the patients convinience by
providing a well-packaged medicine. The best way to prevent any intoxication can be by changing the
used spoon when taking the tablets or directly put the tablets into a package (not necessarily made by
plastics). Also, the clinical staff should be encourage to prevent the medicine from air contact as soon
as possible. Hence, the medicine would not be worn out by the presence of oxygen.
1
2

Medical Records Manual: A Guide for Developing Countries (2002)

Electronic Health Records: A Manual for Developing Countries (2006)

4. Reference

Fda.gov. 2013. Disposal of Unused Medicines: What You Should Know. [online]
Available at:
http://www.fda.gov/drugs/resourcesforyou/consumers/buyingusingmedicinesafely/ens
uringsafeuseofmedicine/safedisposalofmedicines/ucm186187.htm [Accessed: 21 Jun
2013].
Watson, P. 2006. Electronic Health Record: Manual for Developing Countries.
Geneva: Western Pacicic Region.
Watson, P. 2002. Medical Record Manual: A Guide for Developing Countries. Geneva,
Switzerland: Western Pacific Union.
D, Pittet. 2009. WHO Guidelines on Hand Hygiene in Health Care: a Summary. Geneva,
Switzerland: WHO Press.