Evaluation for improving the quality of health records of an emergency prehospital emergency service
Quality of Health Care. Medical Records. Patient safety. Prehospital care.
Improvement cycles can be used to strengthen managerial functions, contributing to the detection of problems or opportunities, with a view to solving and / or improving them. The objective of this study is to evaluate the effect of the implementation of a quality improvement program on filling in the records of occurrences of the Mobile Emergency Care Service (SAMU), in Patos, Paraíba (PB). It is a quasi-experimental study of a time series without control group, divided in six stages: identification and prioritization of improvement, analysis of the opportunity for improvement, construction and validation of quality criterion, evaluation of quality level, intervention, revaluation . Three evaluations were performed between 2016 and 2018 with random sampling of 100 cases in each evaluation, based on seven criteria: identification, clinical evaluation, pathological antecedents, documented registry standardization, legible-correct-accurate registry, professional accountability and Systematization of Care Nursing (SAE). The complete analysis showed failure in all the criteria with emphasis on SAE. Interventions were made in a multifaceted way, grouped by related areas, directed to the quality criteria of worse conformity in the evaluations until new characterization was achieved, with completeness favorable to quality. However, the need for new interventions and monitoring was maintained for the continuity of the be reassessed in 2018 under the same criteria. For the established criteria, the statistically established difference is accepted with Z values of significance <0.001 in 86% of the criteria using SQUIRE 2.0 adapted (2018). The representation of the joint results among the three evaluations was able to highlight progressive improvement in the compliments of each criterion, highlighting the reduction of the defects (not compliments) found, considering the limitations of the study.