Evaluation of the quality of records in medical records of a Brazilian Northeastern Hospital
Health Records, Personal. Communication. Quality of Health Assistance.
The medical record is the communication element among professionals, users and health services that can measure and evaluate the type and quality of the care provided by carrying a set of information about the interventions performed and serving to follow the health history of the user. Proper recording of information becomes an important tool in patient care and safety, as well as legal backing for institutions and professionals. The present study has as general objective to evaluate and improve the records in medical records of Hospital Geral de Farias Brito. The research is a quantitative study, with a quasi-experimental design, before-and-after evaluation of quality criteria. The data were obtained through the analysis of the records made in the records of patients admitted to the unit. An improvement cycle was implemented with problem analysis, intervention and monitoring. Regarding the type of evaluation, it can be stated that it is internal, retrospective and cross-referenced. It was evaluated the eight criteria to verify the quality of the records related to the identification of the patient and the assistant professional, legibility and aspects of the multiprofessional evolution, obtaining satisfactory results, confirming the improvement strategy evaluated.