What indicators of Indigenous patient engagement can be identified in the patient record? A retrospective descriptive study

Aim: To assess the usefulness of patient records to identify indicators of patient engagement for Indigenous patients admitted to hospital for acute cardiac care.

Methods: A retrospective review of 84 patient records at two metropolitan public hospitals from December 2007 to December 2009.

Results: Three overarching themes of patient engagement were identified: communication, compliance and cultural competence. All clinician-patient communication was in English, although a quarter of patients’ records identified language or communication problems. The involvement of families resulted in an improved exchange of clinical information. Compliance appeared to be the responsibility of the patient. Only one measure of cultural competency was identified: the involvement of an Aboriginal Liaison Officer (ALO). Less than half (46%) of patients accessed the ALO, implying a lack of system wide protocols for utilising the ALO. In addition, it was the clinicians who determined access to the ALO.

Conclusion: This study provides an opportunity to examine how information about patient engagement can be included in the medical records to assist in the improvement of patient care for people with cardiac disease.

Implications: The study results raised the question of whether clinician-patient engagement should be defined as an indicator of quality of care and an outcome measure of in-hospital care. A potential outcome measure of clinician-patient engagement would be to quantify the level of patient understanding of their condition and treatment regime, and its long-term implications.