Registros em saúde: avaliação da qualidade do prontuário do paciente na atenção básica, Rio de Janeiro, Brasil

• Autor(a) principal: Vasconcellos, Miguel Murat
• Data de Publicação: 2008
• Outros Autores: Gribel, Else Bartholdy, Moraes, Ilara Hammerli Sozzi de
• Tipo de documento: Artigo
• Idioma: por
• Título da fonte: Cadernos de Saúde Pública
• Texto Completo: https://cadernos.ensp.fiocruz.br/ojs/index.php/csp/article/view/3568
• topic: Atenção Primária à Saúde; Qualidade da Assistência à Saúde; Avaliação de Serviços de Saúde; Registros Médicos

With the purpose of contributing to the evaluation of primary care, a study was conducted based on the quality of patients' health charts, considering the records for care provided in 4 municipalities with more than 100 thousand inhabitants each in the State of Rio de Janeiro, Brazil, in 2004. This was a cross-sectional study based on primary data collected from direct consultation of patient charts. A two-stage, probabilistic cluster sample was selected from primary care facilities and consultations/patient charts. We checked the completeness of attributes pertaining to the identification of users receiving care and the characteristics of the care itself (weight, blood pressure, Pap tests, and blood glucose) on the charts of women over 19 years of age with hypertension and/or diabetes. User identification showed a low presence of social attributes, and only half of the charts had recorded the opening date. Records of process characteristics in care provided to women with hypertension and diabetes failed to conform to Brazilian Ministry of Health guidelines. Analysis of completeness suggests dubious quality in the continuity of the care provided and difficulties in management practice for primary care and implementation of the Family Health Strategy.