Análise dos registros de curativos em prontuários de um hospital de ensino do Estado de Goiás
Autor(a) principal: | |
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Data de Publicação: | 2016 |
Tipo de documento: | Tese |
Idioma: | por |
Título da fonte: | Biblioteca Digital de Teses e Dissertações da UFG |
Texto Completo: | http://repositorio.bc.ufg.br/tede/handle/tede/6268 |
Resumo: | Health records are important for keeping effective communication among all professionals involved in the process of taking care as well as for legitimating the team actions in the face of patients and families. The records must be clear and objective because they are sources of information for judicial, research, teaching, billing and auditing issues. This study has an objective to analyze the records of procedures of Level II Curative in medical records of hospitalized patients, from the nurses’ perspective, before and after the pedagogical intervention, in a Brazilian teaching hospital in the Midwest region. It was a descriptive study with both qualitative and quantitative research and was developed in many stages. The first stage included the nurses’ profiles and the identification of the main reasons why the nursing actions were not recorded. The second stage was the analysis of the records before and after the pedagogical action, which was the third stage. At last, the nurses were interviewed about their perception of the importance of the records for billing. It was observed among the sample of nurses the predominance of women (87,2%), post-graduated (82,1%) and statuary civil servants (80,4%). Even though 53,6% of the nurses said that they do not have double employment relationships, 46,4% said they do. The nurses said that it was not possible to record the procedures due to lack of time (50%), work overload (20%), lack of human resources and access to the records (12,5%), interruptions and lack of guidance (2,5%). The objective of the intervention was to discuss the importance of health records, and specially, in relation to the level II curative. 45,2% of the nurses of this institution took part in this event. In the analysis of the records, before and after the intervention, it was possible to observe the increase of the records of the curatives (82,3%), the detailing of the quantity of curatives per patient (69,9%), the classification of the wounds (63,5%), the description of the materials used in the procedures (67,3%), and also the scheduling (74%) and the checking (71,4%). The data shows that the quantity of material used maintained still. However, there was a rise of curative prescription by the nurses (79,4%) and a fall of curative prescription by the doctors (18,3%). It was also possible to observe that the performed and not prescribed procedures or prescribed and not verified procedures, in both cases, were not billed. Nevertheless, the hospital overturn related to this procedure has an increase, from July 2015. The interviews with the nurses showed that they take the responsibility in the treatment of wounds for themselves. However, it is necessary to standardize the prescriptions and the evolutions of the procedure. The complete record of this intervention is important to safeguard the institution in case of auditing. In conclusion, nurses have an important role in recording the wound treatment. The obligation of recording should be reinforced due to the quality of the service and the profession´s visibility as well as for a better material and input control and billing. |
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Barbosa, Maria Alveshttp://lattes.cnpq.br/5025797873585225Almeida, Alessandra Rodrigues deBarbosa, Nelson BezerraBezerra, Ana Lúcia QueirozPrado, Marinésia Aparecida doBarreto, Regiane Aparecida dos Santos Soareshttp://lattes.cnpq.br/0656597696202359Lemos, Lucimeire Fermino2016-09-26T11:55:01Z2016-06-21LEMOS, L. F. Análise dos registros de curativos em prontuários de um hospital de ensino do Estado de Goiás. 2016. 109 f. Tese (Doutorado em Enfermagem) - Universidade Federal de Goiás, Goiânia, 2016.http://repositorio.bc.ufg.br/tede/handle/tede/6268Health records are important for keeping effective communication among all professionals involved in the process of taking care as well as for legitimating the team actions in the face of patients and families. The records must be clear and objective because they are sources of information for judicial, research, teaching, billing and auditing issues. This study has an objective to analyze the records of procedures of Level II Curative in medical records of hospitalized patients, from the nurses’ perspective, before and after the pedagogical intervention, in a Brazilian teaching hospital in the Midwest region. It was a descriptive study with both qualitative and quantitative research and was developed in many stages. The first stage included the nurses’ profiles and the identification of the main reasons why the nursing actions were not recorded. The second stage was the analysis of the records before and after the pedagogical action, which was the third stage. At last, the nurses were interviewed about their perception of the importance of the records for billing. It was observed among the sample of nurses the predominance of women (87,2%), post-graduated (82,1%) and statuary civil servants (80,4%). Even though 53,6% of the nurses said that they do not have double employment relationships, 46,4% said they do. The nurses said that it was not possible to record the procedures due to lack of time (50%), work overload (20%), lack of human resources and access to the records (12,5%), interruptions and lack of guidance (2,5%). The objective of the intervention was to discuss the importance of health records, and specially, in relation to the level II curative. 45,2% of the nurses of this institution took part in this event. In the analysis of the records, before and after the intervention, it was possible to observe the increase of the records of the curatives (82,3%), the detailing of the quantity of curatives per patient (69,9%), the classification of the wounds (63,5%), the description of the materials used in the procedures (67,3%), and also the scheduling (74%) and the checking (71,4%). The data shows that the quantity of material used maintained still. However, there was a rise of curative prescription by the nurses (79,4%) and a fall of curative prescription by the doctors (18,3%). It was also possible to observe that the performed and not prescribed procedures or prescribed and not verified procedures, in both cases, were not billed. Nevertheless, the hospital overturn related to this procedure has an increase, from July 2015. The interviews with the nurses showed that they take the responsibility in the treatment of wounds for themselves. However, it is necessary to standardize the prescriptions and the evolutions of the procedure. The complete record of this intervention is important to safeguard the institution in case of auditing. In conclusion, nurses have an important role in recording the wound treatment. The obligation of recording should be reinforced due to the quality of the service and the profession´s visibility as well as for a better material and input control and billing.Os registros em saúde são importantes tanto para garantir comunicação efetiva entre todos os profissionais envolvidos no processo de cuidar, quanto para legitimar as ações da equipe junto ao usuário e família. Devem ser claros, e objetivos, pois servem de fonte de informações para questões jurídicas, de pesquisa, ensino, faturamento e auditoria. Este estudo teve por objetivo analisar os registros do procedimento curativo (curativo grau II) nos prontuários de pacientes internados, em um hospital universitário de Goiás, na perspectiva dos enfermeiros, antes e após um treinamento, em hospital de ensino da região Centro-Oeste do Brasil. Tratouse de estudo descritivo, de natureza mista, quanti-qualitativa, desenvolvido em várias etapas. A primeira etapa compreendeu a caracterização do grupo de enfermeiros e a identificação dos principais motivos para a falta de registro das ações de enfermagem. Na segunda etapa, a análise do prontuário procurou em dois momentos, antes e após ação educativa (terceira etapa), identificar o registro. Por último, em entrevista com enfermeiros, verificou-se sua percepção quanto à importância dos registros para o faturamento. Na amostra dos enfermeiros, observou-se predominância feminina (87,2%), de pós-graduados, (82,1%), com vínculo estatutário (80,4%). Embora 53,6% tenham alegado não ter duplo vínculo empregatício, chama a atenção 46,4% alegarem esta condição. Os enfermeiros referem ainda que nem sempre é possível a efetuação dos registros, relatando como motivos: falta de tempo (50%), sobrecarga de trabalho (20%), falta de recursos humanos e acesso à papeleta (12,5%), e interrupções e falta de orientação (2,5%). Realizou-se atividade interventiva, que teve por objetivo tratar de assunto referente à importância do registro em saúde, e especificamente em relação ao curativo grau II, e contou com a participação de 45,2% dos enfermeiros desta instituição. A análise dos prontuários antes a após a intervenção, verificou o aumento dos registros de prescrição de curativos (82,3%), discriminação da quantidade de curativos por paciente (69,9%), classificação das feridas (63,5%), descrição dos materiais utilizados (67,3%), além do aprazamento (74%) e checagem (71,4%). Não se verificou alteração relacionada ao registro da quantidade de materiais. Evidenciou-se aumento das prescrições do procedimento por enfermeiros (79,4%) e diminuição pelos médicos (18,3%). O estudo permitiu ainda identificar procedimentos executados e não prescritos ou prescritos e não checados, em ambos os casos não faturados. Apesar disto, o faturamento do hospital, no que se refere a este procedimento, apresentou aumento a partir de julho de 2015. A entrevista com enfermeiros evidenciou que este profissional assume para si a responsabilidade do tratamento de feridas, mas ainda é necessária a padronização das prescrições e evoluções referentes a este cuidado. O registro completo da intervenção é importante para que a instituição se resguarde em caso de auditoria. O enfermeiro tem papel importante no registro do tratamento de feridas. Deve ser reforçada a obrigatoriedade do registro, tanto para a qualidade do atendimento prestado e visibilidade da profissão, quanto para o melhor controle de materiais e insumos e do faturamento relacionado a este procedimento.Submitted by Cássia Santos (cassia.bcufg@gmail.com) on 2016-09-26T11:13:04Z No. of bitstreams: 2 Tese - Lucimeire Fermino Lemos - 2016.pdf: 4325729 bytes, checksum: 57073bf305b5938110d79f20752057a7 (MD5) license_rdf: 0 bytes, checksum: d41d8cd98f00b204e9800998ecf8427e (MD5)Approved for entry into archive by Luciana Ferreira (lucgeral@gmail.com) on 2016-09-26T11:55:01Z (GMT) No. of bitstreams: 2 Tese - Lucimeire Fermino Lemos - 2016.pdf: 4325729 bytes, checksum: 57073bf305b5938110d79f20752057a7 (MD5) license_rdf: 0 bytes, checksum: d41d8cd98f00b204e9800998ecf8427e (MD5)Made available in DSpace on 2016-09-26T11:55:01Z (GMT). No. of bitstreams: 2 Tese - Lucimeire Fermino Lemos - 2016.pdf: 4325729 bytes, checksum: 57073bf305b5938110d79f20752057a7 (MD5) license_rdf: 0 bytes, checksum: d41d8cd98f00b204e9800998ecf8427e (MD5) Previous issue date: 2016-06-21Fundação de Amparo à Pesquisa do Estado de Goiás - FAPEGapplication/pdfporUniversidade Federal de GoiásPrograma de Pós-graduação em Enfermagem (FEN)UFGBrasilFaculdade de Enfermagem - FEN (RG)http://creativecommons.org/licenses/by-nc-nd/4.0/info:eu-repo/semantics/openAccessRegistros de EnfermagemControle de registrosFaturamentoProcedimento curativoEnfermagemNursing recordsControl recordsBillingCurative procedureNursingCIENCIAS DA SAUDE::ENFERMAGEMAnálise dos registros de curativos em prontuários de um hospital de ensino do Estado de GoiásAnalysis of curative records in medical records of hospitalized patients in a Brazilian teaching hospital in the midwest regioninfo:eu-repo/semantics/publishedVersioninfo:eu-repo/semantics/doctoralThesis45061628303650419816006006006002756753233336908714-7702826533010964327-961409807440757778reponame:Biblioteca Digital de Teses e Dissertações da UFGinstname:Universidade Federal de Goiás (UFG)instacron:UFGLICENSElicense.txtlicense.txttext/plain; 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dc.title.por.fl_str_mv |
Análise dos registros de curativos em prontuários de um hospital de ensino do Estado de Goiás |
dc.title.alternative.eng.fl_str_mv |
Analysis of curative records in medical records of hospitalized patients in a Brazilian teaching hospital in the midwest region |
title |
Análise dos registros de curativos em prontuários de um hospital de ensino do Estado de Goiás |
spellingShingle |
Análise dos registros de curativos em prontuários de um hospital de ensino do Estado de Goiás Lemos, Lucimeire Fermino Registros de Enfermagem Controle de registros Faturamento Procedimento curativo Enfermagem Nursing records Control records Billing Curative procedure Nursing CIENCIAS DA SAUDE::ENFERMAGEM |
title_short |
Análise dos registros de curativos em prontuários de um hospital de ensino do Estado de Goiás |
title_full |
Análise dos registros de curativos em prontuários de um hospital de ensino do Estado de Goiás |
title_fullStr |
Análise dos registros de curativos em prontuários de um hospital de ensino do Estado de Goiás |
title_full_unstemmed |
Análise dos registros de curativos em prontuários de um hospital de ensino do Estado de Goiás |
title_sort |
Análise dos registros de curativos em prontuários de um hospital de ensino do Estado de Goiás |
author |
Lemos, Lucimeire Fermino |
author_facet |
Lemos, Lucimeire Fermino |
author_role |
author |
dc.contributor.advisor1.fl_str_mv |
Barbosa, Maria Alves |
dc.contributor.advisor1Lattes.fl_str_mv |
http://lattes.cnpq.br/5025797873585225 |
dc.contributor.referee1.fl_str_mv |
Almeida, Alessandra Rodrigues de |
dc.contributor.referee2.fl_str_mv |
Barbosa, Nelson Bezerra |
dc.contributor.referee3.fl_str_mv |
Bezerra, Ana Lúcia Queiroz |
dc.contributor.referee4.fl_str_mv |
Prado, Marinésia Aparecida do |
dc.contributor.referee5.fl_str_mv |
Barreto, Regiane Aparecida dos Santos Soares |
dc.contributor.authorLattes.fl_str_mv |
http://lattes.cnpq.br/0656597696202359 |
dc.contributor.author.fl_str_mv |
Lemos, Lucimeire Fermino |
contributor_str_mv |
Barbosa, Maria Alves Almeida, Alessandra Rodrigues de Barbosa, Nelson Bezerra Bezerra, Ana Lúcia Queiroz Prado, Marinésia Aparecida do Barreto, Regiane Aparecida dos Santos Soares |
dc.subject.por.fl_str_mv |
Registros de Enfermagem Controle de registros Faturamento Procedimento curativo Enfermagem |
topic |
Registros de Enfermagem Controle de registros Faturamento Procedimento curativo Enfermagem Nursing records Control records Billing Curative procedure Nursing CIENCIAS DA SAUDE::ENFERMAGEM |
dc.subject.eng.fl_str_mv |
Nursing records Control records Billing Curative procedure Nursing |
dc.subject.cnpq.fl_str_mv |
CIENCIAS DA SAUDE::ENFERMAGEM |
description |
Health records are important for keeping effective communication among all professionals involved in the process of taking care as well as for legitimating the team actions in the face of patients and families. The records must be clear and objective because they are sources of information for judicial, research, teaching, billing and auditing issues. This study has an objective to analyze the records of procedures of Level II Curative in medical records of hospitalized patients, from the nurses’ perspective, before and after the pedagogical intervention, in a Brazilian teaching hospital in the Midwest region. It was a descriptive study with both qualitative and quantitative research and was developed in many stages. The first stage included the nurses’ profiles and the identification of the main reasons why the nursing actions were not recorded. The second stage was the analysis of the records before and after the pedagogical action, which was the third stage. At last, the nurses were interviewed about their perception of the importance of the records for billing. It was observed among the sample of nurses the predominance of women (87,2%), post-graduated (82,1%) and statuary civil servants (80,4%). Even though 53,6% of the nurses said that they do not have double employment relationships, 46,4% said they do. The nurses said that it was not possible to record the procedures due to lack of time (50%), work overload (20%), lack of human resources and access to the records (12,5%), interruptions and lack of guidance (2,5%). The objective of the intervention was to discuss the importance of health records, and specially, in relation to the level II curative. 45,2% of the nurses of this institution took part in this event. In the analysis of the records, before and after the intervention, it was possible to observe the increase of the records of the curatives (82,3%), the detailing of the quantity of curatives per patient (69,9%), the classification of the wounds (63,5%), the description of the materials used in the procedures (67,3%), and also the scheduling (74%) and the checking (71,4%). The data shows that the quantity of material used maintained still. However, there was a rise of curative prescription by the nurses (79,4%) and a fall of curative prescription by the doctors (18,3%). It was also possible to observe that the performed and not prescribed procedures or prescribed and not verified procedures, in both cases, were not billed. Nevertheless, the hospital overturn related to this procedure has an increase, from July 2015. The interviews with the nurses showed that they take the responsibility in the treatment of wounds for themselves. However, it is necessary to standardize the prescriptions and the evolutions of the procedure. The complete record of this intervention is important to safeguard the institution in case of auditing. In conclusion, nurses have an important role in recording the wound treatment. The obligation of recording should be reinforced due to the quality of the service and the profession´s visibility as well as for a better material and input control and billing. |
publishDate |
2016 |
dc.date.accessioned.fl_str_mv |
2016-09-26T11:55:01Z |
dc.date.issued.fl_str_mv |
2016-06-21 |
dc.type.status.fl_str_mv |
info:eu-repo/semantics/publishedVersion |
dc.type.driver.fl_str_mv |
info:eu-repo/semantics/doctoralThesis |
format |
doctoralThesis |
status_str |
publishedVersion |
dc.identifier.citation.fl_str_mv |
LEMOS, L. F. Análise dos registros de curativos em prontuários de um hospital de ensino do Estado de Goiás. 2016. 109 f. Tese (Doutorado em Enfermagem) - Universidade Federal de Goiás, Goiânia, 2016. |
dc.identifier.uri.fl_str_mv |
http://repositorio.bc.ufg.br/tede/handle/tede/6268 |
identifier_str_mv |
LEMOS, L. F. Análise dos registros de curativos em prontuários de um hospital de ensino do Estado de Goiás. 2016. 109 f. Tese (Doutorado em Enfermagem) - Universidade Federal de Goiás, Goiânia, 2016. |
url |
http://repositorio.bc.ufg.br/tede/handle/tede/6268 |
dc.language.iso.fl_str_mv |
por |
language |
por |
dc.relation.program.fl_str_mv |
4506162830365041981 |
dc.relation.confidence.fl_str_mv |
600 600 600 600 |
dc.relation.department.fl_str_mv |
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