MEDICAL RECORD IN ONCOLOGY: AN INSTRUMENT FOR DISEASE AND TREATMENT INFORMATION

• Autor(a) principal: Santos, Bianca Pozza dos
• Data de Publicação: 2015
• Outros Autores: Schwartz, Eda, Feijó, Aline Machado, Muniz, Rosani Manfrin, Zillmer, Juliana Graciela Vestena, Viegas, Aline da Costa
• Tipo de documento: Artigo
• Idioma: por
• Título da fonte: Revista de Atenção à Saúde
• Texto Completo: http://seer.uscs.edu.br/index.php/revista_ciencias_saude/article/view/3190
• topic: Oncologia; quimioterapia; registros médicos; enfermagem.; Medical oncology; drug therapy; medical records; nursing.

Introduction: Knowing the epidemiology of cancer is essential to perform actions, and one of the ways todo this is consulting medical records. As a result, it is necessary to evaluate the quality of available informationin the oncological patients’ medical records, which will enable the continuity of assistance. Objective:To describe the data in the medical records from an oncological service, according to demographic andclinical characteristics, and to chemotherapy. Materials and methods: It is a quantitative study performedat an oncological service. The participants under chemotherapy answered 82 sociodemographic questions.The data about the disease and the treatment was collected from the medical records. For the analysis, weperformed a variable of codifications, elaborated a database, and the quality control occurred throughoutdouble typing. Results: The sample had 221 medical records, from which 117 were from women, and 104from men. The predominant age group was between 51 and 60 years old. The incidence of breast cancer inwomen was 41%, and colon cancer in men, 23,0%, with the prevalence of stage IV. It was highlighted thepalliative chemotherapy for the treatment of the disease. About the planning period of chemotherapy, one totwelve months preponderated, and the chemotherapy cycles were the first. Conclusions: Several data wereincomplete in the medical records, which takes us to lack of information, and can complicate care actions.