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Fulltext Is it my fault? contemplative reactions among nurses toward the existence of blamingculture in relation to their documentation: a Malaysian context

Rekaya Vincent Balang, Robert L. Burton, Nichola A. Barlow

Malaysian Journal of Medicine and Health Sciences, 2020;16(105):19-0.
MyJurnal

Introduction: Nursing documentation is the key to nursing care in hospitals. Nursing documentation contains ev- idences which demonstrate a significant association between the comprehensive level of nursing care and nurses’ professional practice. Therefore, nurses in Malaysia are trained to abide with the code of professional practice (1998) which required them to contrive a complete and comprehensive nursing documentation. Despite the importance of nursing documentation in the nursing professional practice, such study almost non-existent in Malaysia. Hence, there is a need to explore nurses understanding about existence of professionalism within their documentation, from a Malaysian context. Methods: The study utilized a qualitative approach which aimed to explore the perceptions among nurses in Malaysia on their documentation with relation to professionalism in nursing. Forty semi structured interviews were conducted in order to obtain an understanding of nurses’ views on their documentation and its influ- ence on their ways of preparing and completing their documentation. Thematic analysis was used to identify catego- ries and themes in nurses’ accounts of their documentation with relation to professionalism in nursing. Results: One of many profound findings from the study is the fear among nurses of “blaming culture” in that occurs their clinical setting. The nurses perceive “blaming culture” do not tolerate mistakes and they are more likely to be blamed for poor patient safety and insufficient quality of care. This is because nurses are directly involved in delivering care to patient or client in the hospital. “Blaming culture” however motivates nurses to ensure their documentation is com- plete, comprehensive and contemporaneous. Conclusion: Interestingly, the nurses perceive their documentation as an important evidence if there are possible future medical legal issues that they might have to involve with.

Matched MeSH terms: Documentation
Fulltext Medical record abstraction in a hospital with paper-based records: experience of early career psychiatrists in northern Borneo

Ahmad Shahabuddin F, Wah KY, Buji RI, Zulkafli NS, Lee SW, Soon HL, et al.

BJPsych Int, 2020 May;17(2):43-44.
PMID: 32558818 DOI: 10.1192/bji.2019.29

We used medical record abstraction to conduct research in a psychiatric hospital with paper-based medical records. The challenges we encountered included: the difficulty in retrieving files; the extensive effort and time needed to extract clinical information; the lack of a standardised documentation system of medical records; and the need for advanced computer literacy. To promote future research using electronic medical records, potential solutions include creating a registry of all patients receiving treatment, as well as equipping busy clinicians with computer skills.

Matched MeSH terms: Documentation
Fulltext Changing trends in informed consent

Victor Lim

International e-Journal of Science, Medicine & Education, 2014;8(1):3-7.
MyJurnal

Consent is defined as the “voluntary agreement to or acquiescence in what another person proposes or desires”. In the context of medical practice it is now universally accepted that every human being of adult years and of sound mind has the right to determine what shall be done with his or her own body. Informed consent is now a central part of medical ethics and medical law. There has been a change in the public’s expectations of their role in medical decision making. The paternalistic approach by doctors is no longer acceptable. Today the patient has the right to receive and the doctor the obligation to give sufficient and appropriate information so that the patient can make an informed decision to accept or refuse a treatment option. This has led to higher standards of practice in the process of informed consent taking. Consent taking is both a legal and moral requirement. Failure to comply with standards of practice can result in criminal prosecution, civil litigation or disciplinary action by the relevant professional authority. Consent taking is a process and not merely a one-off affixation of the patient’s signature on consent form. It involves a continuous discussion to reflect the evolving nature of treatment from before the treatment is given to the post-operative or discharge period. The regulatory authorities in many countries have established standards for consent taking which would include the capacity of the patient, the person who should seek consent, the information to be provided and the necessary documentation.

Matched MeSH terms: Documentation
Fulltext Healthcare inequalities: the United States vs India

Mohamad Nasaruddin Mahdzir, Izwan Effendy Zainuddin, Sharifa Ezat Wan Puteh

Int J Public Health Res, 2012;2(2):177-183.
MyJurnal

The relationship between healthcare services and inequalities is more likely when a group that shares a salient identity faces severe inequalities of various kinds. Such inequalities may be catalyzed by economic, social, political or concern cultural status. The objectives of this review are to identify the issues and challenges involve in healthcare inequalities, to compare factors contributes to healthcare inequalities and to purpose suggestions and recommendations for improvement based on issues and challenges between United States and India. Comparing annual year healthcare report, documentation of healthcare institutional, Ministry of Health's report and circular, official institutional website, scientific healthcare journals, articles and reports published in 1994 until 2011 regarding healthcare inequalities between United States and India. Health inequalities in the healthcare system contributed by the different in socioeconomic status and accessibility to the healthcare facility due to high cost of treatment has been common risk 'Catastrophic' factors to the inequalities in both countries. Health financing system and resource allocation that benefit only the upper class social spectrum of the population. Disparities occur due to the imbalance in distribution of wealth, discrimination and change in the world economy. Adapting healthcare system that provides care to all classes of people need improvement as no healthcare system is perfect. This matter must be tackle urgently as it's a matter of national concern.

Matched MeSH terms: Documentation
Fulltext Gender Ratio In Undergraduate Medical Program, Medical Faculty, IIUM

Myint, Y.Y., Tun, Y.

International Medical Journal Malaysia, 2008;7(1):0-0.
MyJurnal

Background: Historically, more men enrolled in medical schools than women. However, during the last few decades, there has been an increase in the number of women attending medical schools worldwide. Although a similar trend is seen, there is no documentation found in Malaysia. In this present study, we investigated if such gender enrolment differences occurred at our medical school. Methods: Information was obtained from Kulliyyah of Medicine student statistic for 2006/2007 section and graduates from 2001/2002 (1st batch) to 2006/2007. Results: Our study showed that more than half (60%)of our students are female and all students who received distinction in final year exam from 2002 till now are females although the number of males who needed to sit for the supplementary examination outnumbered the females during that period. Discussion: The feminization of medicine in International Islamic University Malaysia (IIUM) was similar to other studies worldwide. Further research should be aimed on comparison of the academic performance of male and female medical students and also choice of specialty chosen by men and women in our university.

Matched MeSH terms: Documentation
Fulltext Paediatric pharmacology: adverse drug reactions in children

Nafeeza Mohd Ismail

Medical Health Reviews, 2010;2010(1):65-76.
MyJurnal

The safety and efficacy of drugs may be different in children compared to adults. The available documentation at the time of approval for drug use in humans invariably lack data for use in children as generally children are not exposed to medicines in clinical trials. As such, in order to clarify a safety profile in children and to limit the occurrence of adverse drug reactions (ADR), long term data collection is necessary. There is a need to consider how pharmacovigilance is conducted for medicines used by children. It is the ethical responsibility of all health professionals to report ADR. Currently, ADRs in children does not appear to be at a critical level. Certainly, a high standard of care could be a reason but the possibility of health professionals underreporting ADRs has to be considered. Furthermore, many drugs used in children are not licensed for use in this age group. This may further limit the reporting of suspected ADRs to the pharmacovigilance systems.

Matched MeSH terms: Documentation
Fulltext Cloning and Characterization of the Autoinducer Synthase Gene from Lipid-Degrading Bacterium Cedecea neteri

Tan KH, How KY, Tan JY, Yin WF, Chan KG

Front Microbiol, 2017;8:72.
PMID: 28197135 DOI: 10.3389/fmicb.2017.00072

The process of intercellular communication among bacteria, termed quorum sensing (QS), is mediated by small diffusible molecules known as the autoinducers. QS allows the population to react to the change of cell density in unison, in processes such as biofilm formation, plasmid conjugation, virulence, motility and root nodulation. In Gram-negative proteobacteria, N-acyl homoserine lactone (AHL) is the common "language" to coordinate gene expression. This signaling molecule is usually synthesized by LuxI-type proteins. We have previously discovered that a rare bacterium, Cedecea neteri, exhibits AHL-type QS activity. With information generated from genome sequencing, we have identified the luxIR gene pair responsible for AHL-type QS and named it cneIR. In this study, we have cloned and expressed the 636 bp luxI homolog in an Escherichia coli host for further characterization. Our findings show that E. coli harboring cneI produced the same AHL profile as the wild type C. neteri, with the synthesis of AHL known as N-butyryl-homoserine lactone. This 25 kDa LuxI homolog shares high similarity with other AHL synthases from closely related species. This work is the first documentation of molecular cloning and characterization of luxI homolog from C. neteri.

Matched MeSH terms: Documentation
Pull-out and tensile strength properties of two selected tropical trees

Normaniza Osman, Mohamad Nordin Abdullah, Che Hassandi Abdullah

Sains Malaysiana, 2011;40:1123-1127.

A bioengineering technique is gradually being used as an alternative for slope stabilisation design. The effect of vegetation on soil strength, particularly in terms of root reinforcement aspects has therefore become a major interest. However, there is a lack of documentation on the root mechanical properties available especially in Malaysia. In this study, both pull-out and tensile strength of two tropical trees namely Leucaena leucocephala and Acacia mangium were investigated on different stem sizes. L. leucocephala performs the higher pullout strength than A. mangium. The results also show that pullout resistance is much affected by the root than the shoot profiles. In terms of tensile strength, the tensile strength decreases with increasing root diameter, implying the finer root diameter contribute to the higher tensile strength. In both parameters, L. leucocephala exhibits the highest value. The study suggests that L. leucocephala has an added value as a good potential slope plant for slope stabilization work as it exhibits outstanding root mechanical properties. Interestingly, the results also showed that the pullout force was much affected by the tensile strength. It can be concluded that some root and shoot properties do have a great impact on root mechanical properties such as tensile and pullout strengths.

Matched MeSH terms: Documentation
Fulltext Love tragedy, she wrote

Mat Esa MS, Othman Z, Jamil Yaacob M

Malays J Med Sci, 2004 Jan;11(1):86-9.
PMID: 22977365

A case of a 53-year old-single, Kelantanese lady with a diagnosis of paranoid schizophrenia for 28 years is reported with aims to illustrate the influence of life experiences particularly based on education and intelligent on delusion illustrate the evolving nature of the complexity of delusions as well as to show the importance of documentation in psychiatric practice. We concluded that this patient had used defense mechanism of suppression, reaction formation and persecution throughout her delusion. The final persecutory delusion evolved through series of transformation via object of admirations. We postulated that in-depth emotional insight about effects of schizophrenia might have contributed to her self-reflection that have made her frustrated with her poor achievement in life.

Matched MeSH terms: Documentation
Evaluation of medical image watermarking with tamper detection and recovery (AW-TDR)

Zain JM, Fauzi AR

Annu Int Conf IEEE Eng Med Biol Soc, 2007;2007:5662-5.
PMID: 18003297

This paper will study and evaluate watermarking technique by Zain and Fauzi [1]. Recommendations will then be made to enhance the technique especially in the aspect of recovery or reconstruction rate for medical images. A proposal will also be made for a better distribution of watermark to minimize the distortion of the Region of Interest (ROI). The final proposal will enhance AW-TDR in three aspects; firstly the image quality in the ROI will be improved as the maximum change is only 2 bits in every 4 pixels, or embedding rate of 0.5 bits/pixel. Secondly the recovery rate will also be better since the recovery bits are located outside the region of interest. The disadvantage in this is that, only manipulation done in the ROI will be detected. Thirdly the quality of the reconstructed image will be enhanced since the average of 2 x 2 pixels would be used to reconstruct the tampered image.

Matched MeSH terms: Documentation/methods*
Guidelines on retention of pathology records and materials, Part I (version 1/2005)

College of Pathologists, Academy of Medicine of Malaysia, Ministry of Health Malaysia

Malays J Pathol, 2005 Jun;27(1):51-6.
PMID: 16676694
Matched MeSH terms: Documentation/standards
Fulltext Fly artifact documentation of Chrysomya megacephala (Fabricius) (Diptera: Calliphoridae) - a forensically important blowfly species in Malaysia

Zuha RM, Supriyani M, Omar B

Trop Biomed, 2008 Apr;25(1):17-22.
PMID: 18600200

Analysis on fly artifacts produced by forensically important blowfly, Chrysomya megacephala (Fabricius) (Diptera:Calliphoridae), revealed several unique patterns. They can be divided into fecal spots, regurgitation spots and swiping stains. The characteristics of fecal spots are round with three distinct levels of pigmentation; creamy, brownish and darkly pigmented. Matrix of the spots appears cloudy. The round spots are symmetrical and non-symmetrical, delineated by irregular and darker perimeter which only visible in fairly colored fecal spots. Diameter of these artifacts ranged from 0.5 mm to 4 mm. Vomit or regurgitation spots are determined by the presence of craters due to sucking activity of blowflies and surrounded by thickly raised and darker colored perimeter. The size of these specks ranged from 1 mm to 2 mm. Matrix of the spots displays irregular surface and reflective under auxiliary microscope light. Swiping stains due to defecation by flies consists of two distinguishable segments, the body and tail. It can be seen as a tear drop-like, sperm-like, snake-like and irregular tadpole-like stain. The direction of body and tail is inconsistent and length ranged between 4.8 mm to 9.2 mm. A finding that should be highlighted in this observation is the presence of crater on tadpole-like swiping stain which is apparent by its raised border characteristic and reflective under auxiliary microscope light. The directionality of this darkly brown stain is random. This unique mix of regurgitation and swiping stain has never been reported before. Highlighting the features of artifacts produced by flies would hopefully add our understanding in differentiating them from blood spatters produced from victims at crime scenes.

Matched MeSH terms: Documentation*
Fulltext Evaluation of Measles-Mumps-Rubella Vaccination Among Newly Arrived Refugees

Lee D, Weinberg M, Benoit S

Am J Public Health, 2017 05;107(5):684-686.
PMID: 28323479 DOI: 10.2105/AJPH.2017.303698

OBJECTIVES: To assess US availability and use of measles-mumps-rubella (MMR) vaccination documentation for refugees vaccinated overseas.
METHODS: We selected 1500 refugee records from 14 states from March 2013 through July 2015 to determine whether overseas vaccination records were available at the US postarrival health assessment and integrated into the Advisory Committee on Immunization Practices schedule. We assessed number of doses, dosing interval, and contraindications.
RESULTS: Twelve of 14 (85.7%) states provided data on 1118 (74.5%) refugees. Overseas records for 972 (86.9%) refugees were available, most from the Centers for Disease Control and Prevention's Electronic Disease Notification system (66.9%). Most refugees (829; 85.3%) were assessed appropriately for MMR vaccination; 37 (3.8%) should have received MMR vaccine but did not; 106 (10.9%) did not need the MMR vaccine but were vaccinated.
CONCLUSIONS: Overseas documentation was available at most clinics, and MMR vaccinations typically were given when needed. Further collaboration between refugee health clinics and state immunization information systems would improve accessibility of vaccination documentation.

Matched MeSH terms: Documentation*
Portfolio as a learning tool: students' perspective

Elango S, Jutti RC, Lee LK

Ann Acad Med Singap, 2005 Sep;34(8):511-4.
PMID: 16205830

Portfolio writing is a method of encouraging reflective learning among professionals. Although portfolio-based learning is popular among educators, not many studies have been done to determine students' perceptions of portfolio as a learning tool. A questionnaire survey was conducted among 143 medical students to find out their perceptions of the portfolio as a learning tool. A majority of the students felt that the portfolio is a good learning tool. However, they also perceived that it is stressful and time-consuming to develop a proper portfolio. The study indicates that students need appropriate guidance from the academic staff for the system to succeed.

Matched MeSH terms: Documentation
Provision of dysphagia services in a developing nation: Infrastructural challenges

Mustaffa Kamal R, Ward EC, Cornwell P, Sharma S

Int J Speech Lang Pathol, 2015 Dec;17(6):594-604.
PMID: 25874970 DOI: 10.3109/17549507.2015.1026276

PURPOSE: The purpose of the current study was to explore infrastructure issues that may be barriers to the establishment and improvement of dysphagia services in Malaysia compared to settings with established dysphagia management services (i.e. Queensland, Australia).
METHOD: A mixed method design incorporating quantitative and qualitative data was used to increase credibility, validity and comprehensiveness of the results. Thirty-eight hospitals (Malaysia = 21, Queensland = 17) participated in Phase 1 (quantitative component) of the study involving completion of an infrastructure checklist by a speech-language pathologist from each hospital regarding availability of networking and communication, staffing and financial support, facilities and documentation of guidelines for dysphagia management. Subsequently, eight sub-samples from each cohort were then involved in Phase 2 (qualitative component) of the study involving a semi-structured interview on issues related to the impact of infrastructure availability or constraints on service provision.
RESULT: The current study reveals that multiple challenges exist with regard to dysphagia services in Malaysian government hospitals compared to Queensland public hospitals.
CONCLUSION: Overall, it was identified that service improvement in Malaysia requires change at a systems and structures level, but also, more importantly, at the individual/personal level, particularly focusing on the culture, behaviour and attitudes among the staff regarding dysphagia services.

Matched MeSH terms: Documentation
Fulltext Occupational diseases in Malaysia: the need for better notification

Lim HH

Med J Malaysia, 1982 Jun;37(2):98-101.
PMID: 7132840
Matched MeSH terms: Documentation
Fulltext Ethnomedicine in Sabah: past trends and future perspectives

David Matanjun, Mohammad Saffree Jeffree, Freddie Robinson, Falah Abbas Mohamed Salih, Md Shamsur Rahman, Naing Oo Tha

Malaysian Journal of Medicine and Health Sciences, 2019;15(106):82-82.
MyJurnal

Introduction: The objective of this presentation is to carry out a review of the historical status and possible future outlook of the practice of ethnomedicine in the State of Sabah. As in many parts of the world, there are many types of traditional medicines that have been used for hundreds of years among the various native cultural groups in Sabah. Methods: A literature survey was conducted with the aid of online database, and text books using keywords such as the current as well as previous names of Sabah and various related terminology such as ethnomedicine, CAM, complementary and alternative medicine, TCM, traditional and complementary medicine, herbalism, reflexology, spiritualism, ethnobiology ethnology, ethnoanthropology, biological activities, ethnobotanical uses, medicinal prop-erties, toxicity studies, etc. The status of ethnomedicine in Sabah is largely unknown. Results: Based on a review of previous literature, the study discovered that there is limited empirical documentation on the use of ethnomedicine in Sabah. In this preliminary review, a total number of 25 publications were recorded in the databases for the period up to 2019. There is still a need to realise the full potential of the biocultural diversity of Sabah, and that there is a strong need to focus more on socially relevant research. Ethnomedicine in Sabah consists mainly of herbalism, ma-nipulative practices and spiritualism. Plants can be said to be the central player in race-based traditional medicine. While data on ethnomedicine may be based on original field research, several are primarily derivative, drawing as they do from earlier published accounts and, importantly, anecdotes. Traditional massage and other manipula-tive-practices, based on manipulation and movement of body parts, are also popular because of their simplicity and apparent immediate relief that can be experienced by the patient or client. Spiritualism, which may be considered as a peculiar dimension of the mind-body medicine subset of traditional medicine, continues to have its adherents among the natives of Sabah. Conclusion: List and catalogs and sociological and ethnohistorical data were the fa-voured perspective of research in the past; but future evolution of ethnomedical studies need to address some of the debates related to biological, medical and social sciences . Future research should include systematic inves-tigation into efficacy and risk besides the possible incorporation of some parts of ethnomedicine into the existing healthcare services. Ethnomedicine occupies a distinct place in healthcare in the world in general, and Sabah in particular.

Matched MeSH terms: Documentation
Fulltext Descemet membrane detachment postphacoemulsification

Muhammad Najmi, K., Logeswary, K., Rona Asnida, N., Wan Haslina Wah, Umi Kalthum, M.N., Aida Zairani, M.Z.

Medicine & Health, 2018;13(1):208-214.
MyJurnal

We report the case series of phacoemulsification-related Descemet membrane detachment (DMD) encountered at a tertiary hospital in Kuala Lumpur. Case 1 was an iatrogenic DMD which was detected intraoperatively and managed early with good outcome. Case 2 and case 3 described unusual presentation of DMD which was initially undiagnosed. This report highlights the use of anterior segment optical coherence tomography (ASOCT) in detecting and confirming the correct diagnosis for DMD. With the aid of an experienced corneal specialist, the higher threshold for suspicious occurrence of DMD was confirmed using ASOCT. Treatment was tailored accordingly, with successful clearance of corneal oedema and visual recovery. This case series highlighted the importance of proper operative documentation and high threshold for suspicion for DMD in focal corneal oedema following an otherwise uneventful cataract surgery. It is concluded that ASOCT is an excellent tool to confirm diagnosis of DMD and success of treatment.

Matched MeSH terms: Documentation
Fulltext Traditional Jones criteria: limitation in the diagnosis of rheumatic fever in patients with mitral valve repair

Putri Yubbu, Johan Aref Jamaluddin, Lydia Chang Mun Yin, Geetha Kandavello, Mazeni Alwi, Hasri Samion, et al.

Malaysian Journal of Medicine and Health Sciences, 2020;16(2):316-319.
MyJurnal

The present study aims to determine the limitations of traditional Jones criteria during the first episode of acute rheu- matic fever (ARF) at the initial referral hospital, in a cohort of patients below 18 years old who had undergone mitral valve repair in National Heart Institute (IJN) from 2011 to 2016. Carditis followed by fever and joint involvement were the most frequent manifestations at first diagnosis. Of the 50 patients, only seven (14%) fulfilled the traditional Jones criteria for the diagnosis of the first episode of ARF. When compulsory evidence of a previous group A Beta he- molytic streptococcus (GABHS) was disregarded, this figure rose to 54%. Therefore, strict adherence to Jones criteria with absolute documentation of GABHS will lead to underdiagnoses of ARF. The application of echocardiographic diagnostic criteria of rheumatic heart disease (RHD) needs to be emphasized to allow early diagnosis and adminis- tration of secondary prophylaxis to prevent progression to severe valvular disease.

Matched MeSH terms: Documentation
Fulltext Single-Bundle Versus Double-Bundle Arthroscopic Anterior Cruciate Ligament Reconstruction: Comparison of Long-Term Functional Outcomes

Anandan V, Goh TC, Zamri KS

Cureus, 2020 Dec 23;12(12):e12243.
PMID: 33500862 DOI: 10.7759/cureus.12243

Objective To compare long-term functional results of ACL reconstruction with a single bundle (SB) and double bundle (DB). Methods Sixty patients who underwent ACL reconstructions from January 2007 to December 2008 were retrospectively evaluated (30 SB and 30 DB ACL reconstructions). Clinical and functional outcomes were measured pre- and postoperatively in terms of anterior drawer test, Lachman's test, pivot shift test, KT1000 side-to-side difference, range of motion, International Knee Documentation Committee Scoring, Lysholm knee scoring scale (LKS), and Tegner activity level scale. The period of follow-up was 10 years. Results Clinical outcome measured showed that anterior drawer test result were equally normal for both groups (93.3%; p > 0.995); however, the Lachman test was 76.7% in the DB group and 56.7% in the SB group (p > 0.100), the pivot shift was 83% in the DB group and 50% in the SB group (p < 0.001), and KT1000 was 76.7% in the DB group and 56.7% in the SB group (p > 0.100). Regarding the functional outcome, it favored the DB group of patients, with the LKS being statistically significant (p < 0.007) and the Tegner activity level scale p-value being <0.001 Conclusions DB ACL reconstruction produces better rotational stability and gives superior functional outcome in terms of return to pre-injury activity level in comparison to SB reconstruction. DB ACL reconstruction using hamstring tendon autograft produces better functional results at 10 years follow-up.

Matched MeSH terms: Documentation

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