Abstract
Objective: to assess the quality of the written communication of the multiprofessional team in a Unit for Mechanical Ventilation Dependents at a public pediatric hospital. Methods: a quantitative and descriptive research study conducted at a Public Pediatric Hospital, in four stages, namely: identification and prioritization of a quality problem; analysis of the causes of the problem; development of criteria to evaluate the quality level; and assessment of the quality level. Results: 75.0% of the cases of criterion non-compliance are related to date and time recording and to use of electronic medical charts by nurses, physicians and nursing technicians. Physiotherapists presented 32.3% non-compliance in identification of the professionals; among the physicians, the percentage was 8.3%; in the nurses, 68.3%; and in the nursing technicians, 86.7%. Conclusions: absence of date and time in the physicians' and Nursing records was observed, as well as low adherence by the physicians to night evolution in electronic medical charts, and limited access and use of this system by the Nursing team.
References
Agência Nacional de Vigilância Sanitária (BR). Assistência Segura: Uma Reflexão Teórica Aplicada à Prática. Brasília (DF): Anvisa; 2017 [cited 2021 apr 20]. Available from: https://www.saude.go.gov.br/images/imagens_migradas/upload/arquivos/2017-09/2017-anvisa---caderno-1---assistencia-segura---uma-reflexao-teorica-aplicada-a-pratica.pdf
Barrientos Sanchez J, Hernandez Zavala M, Zarate Grajales RA. Factors related to safety and quality of attention in hospitalized pediatric patients. Enferm Univ. 2019;16(1):52-62. https://doi.org/10.22201/eneo.23958421e.2019.1.592
Pedroni VS, Gouveia HG, Vieira LB, Wegner W, Oliveira ACS, Santos MC, et al. Patient safety culture in the maternal-child area of a university hospital. Rev Gaucha Enferm. 2020;41:1-9. https://doi.org/10.1590/1983-1447.2020.20190171
Wegner W, Silva MUM, Peres MA, Bandeira LE, Frantz E, Botene DZA, et al. Patient safety in the care of hospitalised children: evidence for paediatric nursing. Rev Gaúcha Enferm. 2017;38(1). https://doi.org/10.1590/1983-1447.2017.01.68020
Alves KYA. Comunicação escrita dos profissionais de saúde em hospitais públicos do Rio Grande do Norte [dissertation on internet]. Natal: Universidade Federal do Rio Grande do Norte; 2017 [cited 2021 Feb 04]. Available from: https://repositorio.ufrn.br/jspui/bitstream/123456789/24515/1/KisnaYasminAndradeAlves_TESE.pdf
Moreira MCN, Albernaz LV, Sá MRC, Correia RF, Tanabe RF. Guidelines for a line of care for children and adolescents with complex chronic health conditions. Cad Saúde Pública. 2017;33(11):1-13. https://doi.org/10.1590/0102-311X00189516
Biasibetti C, Hoffmann LM, Rodrigues FA, Wegner W, Rocha PK. Communication for patient safety in pediatric hospitalizations. Rev Gaúch Enferm. 2019;40(esp):1-9. https://doi.org/10.1590/1983-1447.2019.20180337
Conselho Federal de Medicina (BR). Resolução Nº 2217, de 27 de setembro de 2018. Aprova o código de ética médica [Internet]. Brasília (DF): CFM; 2002 [cited 2021 Feb 01]. Available from: https://www.in.gov.br/materia/-/asset_publisher/Kujrw0TZC2Mb/content/id/48226289#wrapper
Conselho Federal de Enfermagem (BR). Resolução Nº 514, de 05 de maio de 2016. Guia de recomendações para os registros de enfermagem no prontuário do paciente e outros documentos de enfermagem [Internet]. Brasília (DF): COFEN; 2016 [cited 2021 Feb 01]. Available from: http://www.cofen.gov.br/wp-content/uploads/2016/06/RESOLU%C3%87%C3%83O-COFEN-N%C2%BA-0514-2016-GUIA-DE-RECOMENDA%C3%87%C3%95ES-vers%C3%A3o-web.pdf
Conselho Federal de Fisioterapia e Terapia Ocupacional (BR). Resolução Nº 414/2012, de 23 de maio de 2012. Dispõe sobre a obrigatoriedade do registro em prontuário pelo fisioterapeuta, da guarda e do seu descarte e dá outras providências [Internet]. Brasília (DF): COFFITO; 2012 [cited 2021 Feb 01]. Available from: http://www.crefito.com.br/repository/legislacao/resolu%C3%A7%C3%A3o%20414.pdf
Gama ZAS, Saturno-Hernández PJ, Batista A, Barreto A, Lira B, Medeiros C, et al. Mensuração de boas práticas de segurança do paciente [Internet]. Natal: EDUFRN; 2018 [cited 2021 Feb 01]. 164 p. Available from: https://repositorio.ufrn.br/bitstream/123456789/25874/1/Mensura%C3%A7%C3%A3o%20de%20boas%20pr%C3%A1ticas%20em%20seguran%C3%A7a%20do%20paciente.pdf
Badaró RMMR. Segurança do paciente: avaliação da qualidade da assistência através dos registros em prontuários de pacientes. Rev UNILUS Ensino Pesqui [Internet]. 2019 [cited 2021 Feb 23];16(43):62-73. Available from: http://revista.unilus.edu.br/index.php/ruep/article/view/1126/u2019v16n43e1126
Paim RSP, Bellaver DC, Belmonte J, Azeredo JC. Erros de medicação e segurança do paciente: uma revisão integrativa da literatura. Rev G&S [Internet]. 2016 [cited 2021 Feb 04];7(3):1256-1270. Available from: https://periodicos.unb.br/index.php/rgs/article/view/3660
Souza AFFS, Silveira MM, Beloni Neto MR. Impacto da implantação da prescrição eletrônica nas não conformidades de prescrição em um hospital filantrópico de Presidente Prudente – SP. Colloq Vitae. 2017;9:118 -121. https://doi.org/10.5747/cv.2017.v09.nesp.000307
Santos BRP, Damian IPM. Analysis of information competency through the transition from paper-based to electronic medical records. Rev Cuba Inf Cienc Salud [Internet]. 2017 [cited 2021 Feb 04];28(4):1-13. Available from: https://www.redalyc.org/pdf/3776/377654835003.pdf
Ribeiro MC, Dalaneze BS, Peruchi MPO, Cintra RB. Analysis of medical records of a university hospital in Mogi das Cruzes, São Paulo, Brazil. Rev Bioét. 2021;28(4):740-745. https://doi.org/10.1590/1983-80422020284438
Ghiglia MMC. Historia clínica electrónica: factores de resistencia para su uso por parte de los médicos. Rev méd Urug. 2020;36(2):122-143. http://dx.doi.org/10.29193/rmu.36.2.6
This work is licensed under a Creative Commons Attribution 4.0 International License.
Copyright (c) 2022 Array