Avaliação da qualidade dos registros em prontuários de um Hospital do Nordeste Brasileiro

Abstract

Introduction: the medical record is the communication element among professionals, users and health services that can measure and evaluate the type and quality of the care provided by carrying a set of information about the interventions performed and serving to follow the health history of the user. Proper recording of information becomes an important tool in patient care and safety, as well as legal backing for institutions and professionals. Objective: to evaluate the implantation of the program of improvement of the records in medical records of the General Hospital of Farias Brito. Methodology: quantitative study with almost experimental design of the type before and after evaluation of quality criteria. The data were obtained through the analysis of the records made in the records of patients admitted to the unit. An improvement cycle was performed with problem analysis, intervention and monitoring. Eight criteria were used to verify the quality of records related to patient and assistant identification, legibility and aspects of multiprofessional evolution. The results were presented through the Pareto Chart, in which it was observed if there was an improvement in quality and its significance. Results: In the initial measurement, compliance rates of 36.30% were observed on average, with emphasis on criterion 4, which says that the records in the medical records must contain the professional identification, date, time and number of the class council, with 100.00% non-compliance. In the second measurement, an average increase in compliance with all criteria was observed at 19.45%. Conclusion: Considering the improvements achieved, it is perceived that the improvement cycle is an effective tool for the quality of services specially developed for medical records.