文章基本信息

标题：Inconformidades nos registros em prontuários: opinio dos trabalhadores de saúde
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作者：Ludimila Cristina Souza Silva ; Marinésia Aparecida do Prado ; Marcos Rassi Fernandes 等
期刊名称：Research, Society and Development
电子版ISSN：2525-3409
出版年度：2021
卷号：10
期号：12
页码：1-8
DOI：10.33448/rsd-v10i12.20587
语种：English
出版社：Grupo de Pesquisa Metodologias em Ensino e Aprendizagem em Ciências
摘要：The objective was to verify the opinion of health workers about the non-conformities of records in hospitalized patients' medical records. Descriptive-analytical study, with a qualitative approach, carried out in a public health institution in Brazil. 30 health workers from different areas participated. A self-administered instrument with open questions was used. Data were organized using the ATLAS ti software and Bardin's content analysis. Among the main nonconformities, incorrect or incomplete records (90.9%), illegible handwriting or erasures (27.2%) and absence of records (12.1%) were highlighted. As for the causes of such nonconformities, lack of interest (54.5%), ignorance of the legality of registration (27.2%), overload and deficit of human resources (24.2%) insufficiency of qualification and knowledge were identified. of workers on the subject (24.2%). In view of the evidence pointed out in the study, it is recommended to review the workers' qualification policy, together with the elaboration of protocols, adequacy of forms for records and careful organization of medical records.
关键词：Records;Medical record;Nonconformities;Health workers.