Avaliação do preenchimento de prontuários médicos em um hospital geral

Abstract

Background: To describe the fulfilment of medical records from patients with cancer hospitalizated in a referral hospital. Methods: A cross - sectional study carried out at a Hospital of Rio Grande do Sul, Brazil, in which the frequency of 25 items (relative to patient identification and care) was analyzed in medical records of patients with malignant neoplasia hospitalized throughout 2017. Results: A total of 258 items were processed, of which 11 were identification items, 10 were distributed in almost all cases, except for the provenance (41,9%; n=108). Among the 14 items related to the care of the disease, location of primary tumor (93%; n=240), conduct (89,9%; n=232), reason of hospitalization (84,9%; n=219) and summary of discharge/death (84,1%; n=217) presented a higher frequency of recording. The least completed were: internacional classification of malignant tumours (32,6%; n=84) and family history (26%; n=67). Conclusions: Although with better results to those described in the literature, the fulfilment of the medical records analyzed was incomplete. The use of standard template and checklists can be effective in improving punctual items that are still poorly filled. The awareness of its importance is fundamental in order to improve the fulfilment of the medical record.