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Type: Artigo de periódico
Title: Incomplete Medical Record In Emergency Service: A Barrier For The Quality In Health [prontuário Incompleto No Pronto-socorro: Uma Barreira Para A Qualidade Em Saúde]
Author: Carvalho R.D.S.
Kara-Jose N.
Noma R.K.
Chignalia M.Z.
Novaes H.M.D.
Abstract: Purpose: scrutinize the filling of medical records in Ophthalmology emergency services, in order to provide grounds for the evaluation of the service quality. Materials and methods: we have analyzed the filling of medical records (administrative forms) by the residents of the Emergency Service of the "Hospital das Clínicas" of the Medical School of São Paulo University, during a regular week on duty. Results: the sample was composed of 584 medical records. In 57 (9,8%) the destination of the patients was not mentioned; in 16 (2,7%) the name of the medical doctor who attended the patient was not mentioned; in 15 (2,6%) the attending medical doctor did not provide the respective enrollment number at the Regional Medicine Council. As regards the diagnosis, to 6,0% the handwriting of the attending medical doctor was illegible and to 6,3% only the Disease International Code was mentioned. To 33,4% the anamnesis was not mentioned at the medical record (including eye trauma cases). Conclusion: we have found mistakes at the filling of medical records in an ophthalmology urgency college service, that may cause problems to the hospital and even to the medical doctor, by lack of payment of the services rendered, by decreasing patterns of quality of the medical care, by the impossibility of defense in case of litigation founded on medical malpractice and by deficiencies on education and research. © Copyright Moreira Jr. Editora.
Rights: fechado
Identifier DOI: 
Date Issue: 2009
Appears in Collections:Unicamp - Artigos e Outros Documentos

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