Análise de prontuários de hospital universitário de Mogi das Cruzes, São Paulo

Abstract

Resumo O prontuário médico é, na área da saúde, documento básico que permeia toda a atividade assistencial, administrativa, de pesquisa e de ensino, permitindo a comunicação entre os diversos profissionais que participam do cuidado do paciente. Destaca-se, no entanto, a diferença de qualidade dos registros produzidos por cada instituição. Considerando essa variedade, o objetivo desta pesquisa foi analisar prontuários de um hospital de ensino de Mogi das Cruzes/SP. Foram avaliados 191 prontuários, datados a partir de 2016. A avaliação consistiu na aplicação de instrumento que atribui escores considerando os itens obrigatórios do prontuário. Apesar de os escores totais obtidos não serem baixos, os resultados demonstram que a qualidade dos prontuários varia e que o hospital-escola deve aperfeiçoar seu preenchimento.

Transtornos mentais e de comportamento associados ao puerpério e seus fatores influenciadores em unidades de saúde da família no município de Cascavel – PR

“…Sobre a confiabilidade dos prontuários, Conselho Federal de Medicina (CFM), no artigo 1º da Resolução CFM 1.638/2002, define prontuário médico como o documento único constituído de um conjunto de informações, sinais e imagens registradas, geradas a partir de fatos, acontecimentos e situações sobre a saúde do paciente e a assistência a ele prestada, de caráter legal, sigiloso e científico, que possibilita a comunicação entre membros da equipe multiprofissional e a continuidade da assistência prestada ao indivíduo (Ribeiro, et al, 2020). Os prontuários analisados de 2020 apresentavam informações satisfatórias sobre a história médica das pacientes.…”

Avaliação da comunicação para melhoria da qualidade da assistência à saúde em pediatria: estudo descritivo

“…This segregation between the professionals is clear and can have consequences for the care of patients with CCCs, as effective communication generates safety in the actions offered, reducing the number of adverse events and unfavorable outcomes (4,7) . This fact becomes worrisome because the Nursing team is the key to strengthening communication across several teams, as it is uninterruptedly providing care to the patients and can be a link between the various professionals, being important that their records can be read and evaluated in a multiprofessional way (7,16) . Thus, this division in communication can promote room for severe failures in the care process.…”

“…From this perspective, in a study with a university hospital, one of the barriers to implementing electronic medical charts would be obtaining resources for their acquisition, in addition to adherence by the team. Thus, considering that the hospital has an electronic medical chart system, it would be fundamental to reduce underutilization in order to improve quality of the records (16) . In this research, concentration of approximately 75% of the non-compliance cases that correspond to the general criteria of date and time and professional evolution is noticed.…”

“…A number of studies conducted to analyze the causes that lead to failures in the records of the medical charts point out the following as the main causes: inattention and disinterest by the professional; work overload; lack of knowledge about legality of the records; interference in the physician-patient relationship; the time for recording data in the system, which is longer at the beginning and is reduced with adaptation and incorporation into the work routine; and fear and distrust towards the technological resource and its possible instability (4,7,(16)(17) . As was done in these studies, designing the local scenario and recognizing the limitations that interfere with adherence to the use of electronic medical charts are fundamental guidelines for outlining the necessary interventions for better adherence to electronic medical charts and to good recording practices.…”

“…Integration of the multiprofessional team is feasible through effective communication tools and has positive consequences for quality of the services and for patient safety, with the possibility of optimizing resources and outlining more resolute plans regarding the care to be provided to the clients (5) . Thus, therapeutic plans should be elaborated for children with CCCs, in order to hold all the professionals involved in this process accountable, to effectively implement the care to be provided and ensure multidisciplinary analysis, developed with the improvement of communication between the professionals (7,12,(16)(17) . Therefore, investing in improving the written communication tool already available is an important strategy, given the impact it can exert on these children's lives.…”