INPATIENT INSTALLATION

DISCHARGE GUIDELINES AT
THE BALI MANDARA REGION
GENERAL HOSPITAL
BALI PROVINCE
INPATIENT INSTALLATION DISCHARGE GUIDELINES
AT THE BALI MANDARA REGIONAL GENERAL
HOSPITAL, BALI PROVINCE

BALI MANDARA REGIONAL GENERAL

HOSPITAL BALI PROVINCE
2022
GUIDE

RETURN OF PATIENTS TO INPATIENT

INSTALLATIONS

Document Writing : Inpatient Installation

Date : 13 June 2022

Total Page : 19
 PEMERINTAH PROVINSI BALI

DINAS KESEHATAN

RSUD BALI MANDARA

JALAN BY PASS NGURAH RAI NOMOR 548 SANUR - DENPASAR, BALI (80227)
EMAIL : rsud.balimandara@gmail.com, WEBSITE : https://rsbm.baliprov.go.id

DIRECTOR’S DECISION

BALI MANDARA REGIONAL GENERAL HOSPITAL BALI PROVINCE

NUMBER B.37.188.4/28697/HHP/RSBM

ABOUT

IMPLEMENTATION OF PATIENT DISCHARGE GUIDELINE FOR INPATIENT

INSTALLATIONS AT BALI MANDARA REGIONAL GENERAL HOSPITAL
BALI PROVINCE

DIRECTOR OF BALI MANDARA REGIONAL GENERAL HOSPITAL BALI PROVINCE

Considering : a. That in an effort to improve the quality of service, identify needs during
patinet discharge and document patient discharge at the inpatient
installation at Bali Mandara Regional General Hospital, Bali Provoince.

b. That for the smooth implementation as intended in letter (a) a guide for
discharge of inpatient isntallation patients is required.

c. That based on the considerations as intended in letters (a) and (b), it is

necessary to stipulate a Director’s Decree regarding The Implementation
of Guidelines for the Discharge of Inpatient Installation Patient at Bali
Mandara Regional General Hospital, bali Province.

Remember: 1. Law Number 64 of 1958 concerning the Establishment of the level I

Regions of Bali, West Nusa Tenggara (State Gazette of the Republic of
Indonesia of 1958 Number 115, Supplement to the State Gazette of
Republic of Indonesia Number 1694);
2. Law Number 29 of 2004 concerning Medical Practice (State Gazatte of
the Republic of Indonesia of 2004 Number 116, Supplement to State
Gazette of the Republic of Indonesia Nmber 4431;
3. Law Number 29 of 2009 concerning Public Services (State Gazatte of
the Republic of Indonesia of 2009 Number 112, Supplement to State
Gazette of the Republic of Indonesia Number 5038;
4. Law Number 36 of 2009 concerning Health (State Gazatte of the
Republic of Indonesia of 2009 Number 114, Supplement to State
Gazette of the Republic of Indonesia Number 5063 as amended by Law
Number 11 of 2020 concerning job creation (2020 state gazette of the
Republic of Indonesia number 245, supplement to the state gazette of
the Republic of indonesia number 6573);
5. Law Number 44 of 2009 concerning Hospitals (State Gazette of the
Republic of Indonesia of 2009 Number 53, Supplement to State Gazette
of the Republic of Indonesia Number 5072) as amended by Law
Number 11 of 2020 concerning Job Creation (State Gazette of the
Republic of Indonesia of 2020 Number 245, Supplement to the State
Gazette of the Republic of Indonesia Number 6573);

6. Law Number 23 of 2014 concerning Regional Government (State Gazette

of the Republic of Indonesia of 2014 Number 244, Supplement to State
Gazette of the Republic of Indonesia Number 5587) as amended several
times, most recently by Law Number 1 of 2022 concerning Financial
Relations between the Central Government and Regional Government
(State Gazette of the Republic of Indonesia 2022 Number 4, Supplement to
the State Gazette of the Republic of Indonesia Number 6757);

7. Law Number 36 of 2014 concerning Health Workers (State Gazette of the

Republic of Indonesia of 2014 Number 298, Supplement to State Gazette
of the Republic of Indonesia Number 5607);

8. Law Number 38 of 2014 concerning Nursing (State Gazette of the

Republic of Indonesia of 2014 Number 307, Supplement to State Gazette
of the Republic of Indonesia Number 1609);
9. Minister of Health Regulation Number 269/MENKES/PER/III/2008
concerning Medical Records;
10. Minister of Health Regulation Number 290/MENKES/PER/III/2008
concerning Approval of Medical Procedures;

11. Minister of Health Regulation Number 1438/MENKES/PER/IX/2010

concerning Medical Service Standards (State Gazette of the Republic of
Indonesia of 2010 Number 464);
12. Minister of Health Regulation Number 11 of 2017 concerning Patient
Safety (State Gazette of the Republic of Indonesia of 2017 Number 308);

13. Minister of Health Regulation Number 34 of 2017 concerning Hospital

Accreditation (State Gazette of the Republic of Indonesia of 2017 Number
1023);
14 Regulation of the Governor of Bali Number 115 of 2016 concerning the
Establishment of the Organizational Structure and Work Procedures of the
Bali Mandara Regional General Hospital, Bali Province (Regional Gazette
of the Province of Bali, 2016 Number 115);
15 Regulation of the Governor of Bali Number 47 of 2017 concerning
Minimum Service Standards for the Technical Implementation Unit of the
Bali Mandara Regional General Hospital, Bali Province (Bali Province
Regional Gazette of 2017 Number 47);
16 Governor Regulation of Bali Number 71 of 2017 concerning Internal
Regulations of Bali Mandara Regional General Hospital (RSUD) Technical
Implementation Unit, Bali Province (Bali Province Regional Regulation
Number 71 of 2017).
DECIDE

First: To enact the Patient Discharge Guidelines for the Inpatient Installation at Bali Mandara
Regional General Hospital, Bali Province.

Second: Enforcing the Patient Discharge Guidelines for the Inpatient Installation at Bali Mandara
Regional General Hospital, Bali Province, prepared by the Inpatient Installation on June 13,
2022, consisting of 20 pages, established as guidelines at Bali Mandara Regional General
Hospital.

Third: The Head of the Inpatient Installation is responsible for socializing the guidelines as
referred to in the second paragraph and reporting the results of activities to the Deputy Director
of Services at Bali Mandara Regional General Hospital.

Fourth: The Deputy Director of Services provides guidance and supervision on the
implementation as referred to in the second paragraph and reports the results of activities to the
Director of Bali Mandara Regional General Hospital.

Fifth: This decision shall take effect from the date of its establishment with the provision that if
there are errors in this decision in the future, corrections shall be made accordingly.
 FOREWORD

First of all, we would like to express our gratitude to God Almighty/lda Sang Hyang Widhi
Wasa for the success in preparing the Patient Discharge Guide at the Bali Mandara Regional
Hospital. This guide plays a role in increasing the awareness of hospital leaders, staff, management
and employees in implementing patient discharge.
The Patient Discharge Guide aims to serve as a reference for implementing steps for
returning patients so that patients understand the medical procedures or subsequent treatment
actions to improve the patient's health and the quality of services at the hospital.
On this occasion we would like to thank all parties who have given their time and thoughts
to support and participate in the preparation of the Patient Discharge Guidebook from the
beginning until the publication of this book. Hopefully it will be charity and goodness for all of us.
We hope for support from various parties so that this guidebook can be used as a reference
in health services in hospitals.
 LIST OF CONTENTS

VALIDITY SHEET
FOREWORD............................................................................................................. i
LIST OF CONTENT ................................................................................................ ii
CHAPTER I UNDERSTANDING........................................................................... 1
CHAPTER II SCOPE...... .......................................................................................... 2
CHAPTER III GOVERNANCE................................................................................ 4
CHAPTER IV DOCUMENTATION........................................................................ 9
 ATTACHMENT I

DIRECTOR'S DECISION
BALI MANDARA REGIONAL GENERAL HOSPITAL, BALI PROVINCE

DATE 13 OF JUNI 2022

NUMBER B.37.188.4/28697/HHP/RSBM

ABOUT

PATIENT DISCHARGE GUIDELINES AT THE TECHNICAL IMPLEMENTATION UNIT OF

THE BALI MANDARA REGIONAL GENERAL HOSPITAL, BALI PROVINCE

CHAPTER 1
A. Understanding
Patient discharge is a systematic planning process prepared for patients to leave the care
facility (hospital) and to maintain continuity of care. The process of discharging patients
from the hospital is carried out based on patient discharge criteria and the need for
continuity of care and actions.

Discharging patients to home or family is based on the patient's health condition and their
need to obtain continuity of care. Patients may also be referred or sent to healthcare
practitioners outside the hospital. Attending physicians and other relevant healthcare
professionals responsible for patient care determine the patient's readiness to leave the
hospital based on policies, criteria, and referral indications set by the hospital. The need
for continuity of care means referral to specialist doctors, physical rehabilitation, or even
the need for preventive efforts at home coordinated by the patient's family. A well-
organized process is needed to ensure that continuity of care is managed by healthcare
practitioners or an organization outside the hospital. Patients who require discharge
planning, then the hospital begins planning for it as early as possible, preferably to ensure
continuity of care is integrated involving all relevant healthcare professionals and
facilitated by the Discharge Planning Coordinator. Families are involved in this process as
needed.

1
 CHAPTER II
SCOPE

The continuity of service requires special preparation and considerations for certain
patients, such as the discharge planning of Bali Mandara Regional General Hospital patients,
which establishes mechanisms for patient discharge criteria, criteria for patients requiring
discharge planning (P3), and criteria for patients requiring continuity of care.
The scope of patient discharge includes all areas of care, both outpatient, inpatient, and
emergency care. Patient discharge criteria are established based on the patient's general
condition (stable condition and normal vital signs) or based on Clinical Practice Guidelines
(CPGs).
Meanwhile, the scope of discharge planning covers inpatient areas. For inpatients, not all
patients are planned for discharge planning, but only those who meet the criteria that require
further management while at home. The criteria that require patient discharge planning
(P3/Discharge Planning) are:

1. Elderly patients (above 60 years old) with memory impairment

2. Low birth weight infants
3. Patients with mobility impairments
4. Patients still requiring assistance to continue therapy or continuous care
5. Patients needing assistance with daily activities

Patients who require continuity of care and further management after discharge from the hospital
include:

1. Stroke
2. Heart attack
3. Chronic Obstructive Pulmonary Disease (COPD)
4. Diabetes Mellitus with insulin treatment
5. Congestive heart failure
6. Emphysema
7. Dementia
8. Alzheimer's disease
9. AIDS
10. Multiple trauma or other life-threatening diseases
11. Patients who still need to be readmitted within 30 days
12. Age above 60 years
13. Patients coming from nursing homes
14. Living alone without direct social support
15. Unknown address or coming from out of town
2
16. Unrecognized patients/ no identification or homeless
17. Unemployed/ no insurance
18. Suicide attempt
19. Victims of criminal cases

3
 CHAPTER III
GOVERNANCE

Patient discharge has specific provisions to create conditions that are not detrimental to both
the patient and the hospital.

1. Patient discharged
Procedures for Patient Discharge
a. The Attending Physician (DPJP) visits and declares that the patient is fit for discharge
(BPL) based on the patient's stabilized condition and normal vital signs. Patients who
have been deemed fit for discharge are advised to return for follow-up according to the
time determined by the DPJP.
b. The attending doctor/MOD (Medical Officer on Duty) requested by the DPJP for
inpatient care after examination reports the patient's condition to the attending
doctor/MOD, stating that the patient's condition has improved and is expected to be
discharged or undergo outpatient care. The attending doctor/MOD then reports the
examination results and the patient's actual condition to the DPJP as clearly as possible.
Subsequently, the DPJP allows BPL, which is then documented by the attending
doctor/MOD in the CPPT (Continuous Patient Progress Tracking) form, including the
signature and clear name of the attending doctor, and this can be considered patient
discharge BPL.

Flow and Stages of Patient Discharge

a. The Attending Physician (DPJP) states in the CPPT that the patient in question is
declared BPL, either written directly by the DPJP or by the MOD (Manager On Duty)
doctor with DPJP's approval.
b. The existence of a BPL certificate or discharge letter written directly by the DPJP or by
the MOD doctor with DPJP's approval.
c. The breakdown of costs made by the staff, which includes the total cost of treatment
during the patient's stay, for self-paying or general expenses. For patients using
insurance, the breakdown of costs does not need to be given to the patient, but still
provide a discharge letter and prescription. The breakdown of insurance costs must still
be provided to the staff, but it is the inpatient staff who must give it to the patient.
Insured patients do not need to know the treatment costs.
d. Providing the results of supporting examinations to the patient or family, including
radiology results, laboratory results, and others without exception, by handing over the
original sheet and leaving a copy in the patient's status. For patients with general or
insured expenses, all results are given to the family or patient and it is suggested that
the patient or family bring them back for follow-up.

4
e. Pharmacy provides information to the patient or patient's family about the medications
to be taken home.
f. Nurses re-explain to the patient or family about the discharge letter that has been given
to the patient or family.
g. Nurses provide information to the patient about when to return for follow-up, when to
return under certain circumstances without waiting for the follow-up appointment,
home care related to the patient's illness or condition, the use of prescribed medications
according to the rules given by the attending doctor, what activities or foods are
allowed for the patient. This explanation is done through good communication to make
it easily understood by the patient and family. These instructions can be given not only
to the patient but also involve the family to play a role in home care.
h. Staff removes all medical equipment attached to the patient, such as O2, IV lines,
catheters, NG tubes, or others attached to the patient. Except for cases where the patient
needs to bring medical equipment or at the recommendation of the DPJP due to specific
cases.
i. Patients who are ready to leave if they use their own or private vehicles and are ready
to leave, the staff escorts the patient with suitable transfer equipment according to the
patient's condition. For example, a wheelchair if the patient is able to sit, a stretcher if
the patient is unable to sit.
j. If the patient requests transportation by hospital ambulance, if the ambulance and staff
are ready and the family has shown ambulance administrative clearance, the staff
escorts them to the ambulance with appropriate transfer equipment for the patient.

Filling in or completing the status by the attending staff for discharged patients
(BPL).

a. When the DPJP declares BPL for the patient, the DPJP must complete the discharge
summary. The completion of this form is done by the DPJP or the general practitioner
discharging the patient. The discharge summary includes:

1) Reason for admission, diagnosis, and other comorbidities.

2) Important physical findings and other observations.
3) Diagnostic procedures and therapeutic procedures performed.
4) Medications given during hospitalization with potential residual effects after
discontinuation, and all medications to be used at home.
5) Patient's condition (current status).
6) Follow-up instructions.

b. The staff (nurse) completes the admission and discharge summary sheet in the patient
discharge section.
5
c. Completion of the patient's status should be done within 24 hours after the patient is
discharged, and it is preferably completed as soon as the patient is free from any
equipment installed or provided in the hospital.

Voluntary Discharge Against Medical Advice (AMA)

Procedures for voluntary discharge or discharge against medical advice
a. The DPJP provides explanations and information to the patient and family about the
patient's condition, the dangers, risks, and various possibilities that may arise if
inpatient treatment is not continued.
b. The family or patient signs a form declaring voluntary discharge.

Flow of Patients Discharged Against Medical Advice (AMA) or Voluntarily

a. After receiving explanations from the DPJP and signing the voluntary discharge
consent form, the nurse advises the patient's family to complete administrative
procedures at the cashier.
b. The payment receipt is provided at the payment administration section.
c. Staff removes all medical equipment attached to the patient.
d. The nurse provides any remaining oral medications.
e. For patients with weakened conditions, they are escorted to the hospital lobby using a
wheelchair or stretcher.
f. The DPJP completes the discharge summary by checking the AMA box and providing
the reason for the patient's request for AMA.
g. Staff complete the nursing/midwifery care documentation and write in the register book
the reasons for the patient's AMA.

Deceased Patients
Procedure for discharging deceased patients
The discharge of deceased patients refers to the discharge of patients whose condition is no
longer alive or who have passed away. The discharge of deceased patients is done because
the patient has died in the hospital due to a condition that cannot be saved by the hospital
staff. The discharge of deceased patients can be done after the patient has been officially
declared dead by the staff, accompanied by medical examination evidence, such as an EKG
showing asystole or indicating that the patient has died, or based on assessments made by
the staff, such as cessation of breathing, no longer palpable carotid pulse, cardiac arrest, and
clinical signs of death such as bluish discoloration of the brain stem, dilated pupils, and
others. After such assessment, the staff or doctor has declared the patient dead and written a
death certificate, the patient is then clearly declared dead and can undergo the service of
discharging deceased patients. In patients who have been declared dead, the discharge
process must wait for a minimum of 2 hours after the patient has been declared dead. The

6
patient must be placed away from other patients to avoid direct contact with other patients
or causing fear or disturbance to other patients. After 2 hours, the deceased patient can be
placed in the morgue. If there is another deceased person in the morgue at that time and the
morgue is already full, the deceased can be placed in another room, as long as it is a
separate room where the patient is not in the same room with other patients. After the death
certificate has been issued by the staff, the staff must also prepare an itemized bill that must
be settled by the family. The death certificate is given to the patient's family once they have
settled the hospital bill. The deceased patient can be transported home by hospital
ambulance accompanied by hospital staff (hucare). Alternatively, if the family prefers, they
can use their own vehicle, but the staff does not need to accompany them. If the family does
not want to wait for 2 hours before being allowed to take the deceased home, the staff
should still motivate the family and explain to them why they need to wait 2 hours
according to hospital procedures. If the family still refuses after being explained and
motivated by the staff, any subsequent undesirable events will not be the responsibility of
the hospital but the responsibility of the family. Once the patient's family has settled the
hospital administrative fees, in addition to the death certificate given to the family, the staff
must provide all results of supporting examinations such as laboratory tests and X-rays.

Flow and Stages of Discharging Deceased Patients

a. There is a statement from the DPJP that the patient has passed away, documented in the
DPJP's travel sheet and the death certificate.
b. The family has been informed, which can be done by the DPJP.
c. Removal of medical equipment attached to the patient and the staff adjusting the
position of the deceased.
d. The itemized bill has been prepared and must be handed over to the family, and the
family settles it.
e. Deceased patients must wait for 2 hours before being taken to the morgue or a specific
room or their own room, where they are not placed in the same room as other
inpatients.
f. For families who have agreed to wait for 2 hours but still wish to take the deceased
home before 2 hours, the body can be taken home with the family by filling out and
signing an education form stating that they are willing to bear all risks that occur if
taken home before the designated time.
g. Removal of the deceased's wristband when leaving.

Patient Escapes
Procedure for patient escape
a. Immediately after knowing the patient has escaped, the ward nurse reports to the head
of the ward.
7
b. The head of the ward forwards the report to the information section to call the patient
via voice announcement up to 3 times with a 10-minute interval.
c. The head of the ward contacts the Public Relations and Legal Affairs sub-department to
contact or search for the family of the escaped patient.
d. The Public Relations and Legal Affairs sub-department coordinates with the security
unit to jointly search for the family of the escaped patient.
e. If the patient's family is found, they are directed to the finance department of Bali
Mandara Regional General Hospital. If not found, the Public Relations and Legal
Affairs sub-department reports the escaped patient to the police.

Leaving the Hospital Against Medical Advice (AMA)

If a patient has completed a thorough examination and there is a recommended course of
action, but then decides to leave the hospital, they can be considered as leaving against
medical advice. Both inpatient and outpatient (including patients from the emergency
department) have the right to refuse medical treatment and leave the hospital. These patients
face risks as they receive incomplete treatment or intervention, which may result in
permanent damage or death. If an inpatient or outpatient requests to leave the hospital
without the doctor's approval, the patient must be informed about the medical risks by the
doctor who created the care plan or treatment plan, and the patient's family process should
comply with hospital regulations.

8
 CHAPTER IV
DOCUMENTATION

Documentation carried out for the management of patient discharge from the
hospital includes:
1. Patient discharge management is conducted according to procedures.
2. Completeness of documentation according to patient discharge category.
3. Completion of discharge summary (by doctor and nurse).
4. Completion of discharge planning files.