Análise do preenchimento de prontuários médicos em um ambulatório de ensino

Abstract

Objective: To describe the compliance of medical records completion in a teaching outpatient clinic with legislation and literature. Methods: This was a cross-sectional study conducted in Passo Fundo, RS, using data from the electronic medical record system of a teaching outpatient clinic. The sample comprised records of outpatient visits conducted from January 2022 to December 2023. The completion of 18 items in each analyzed record was verified, and one point was assigned for each correctly filled item. Based on the total score of each medical record, central tendency measures were verified for the entire sample and for each specialty studied (Pulmonology, Nephrology, Cardiology, Gynecology, and Gastroenterology). A statistical test (Kruskal-Wallis) was applied to compare completion among the different specialties. Results: The sample consisted of 270 medical records. The items with the lowest completion rates were Occupation (25.56%) and Review of Systems (30%). A total of 59.63% of the medical records were considered to have adequate completion. Furthermore, 48.15% of the records contained patient instructions considered well-detailed. No statistically significant difference was observed in the completion of medical records among the different specialties analyzed. Conclusion: The quality of medical records completion in the teaching outpatient clinic is partial, with specific deficiencies in certain items, but without disparity among specialties.