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[健康记录:巴西里约热内卢初级保健中患者健康图表的评估]

[Health records: evaluation of patient health charts in primary care, Rio de Janeiro, Brazil].

作者信息

Vasconcellos Miguel Murat, Gribel Else Bartholdy, Moraes Ilara Hammerli Sozzi de

机构信息

Departamento de Administração e Planejamento em Saúde, Escola Nacional de Saúde Pública Sergio Arouca, Fundação Oswaldo Cruz, Rio de Janeiro, Brazil.

出版信息

Cad Saude Publica. 2008;24 Suppl 1:S173-82. doi: 10.1590/s0102-311x2008001300021.

Abstract

With the purpose of contributing to the evaluation of primary care, a study was conducted based on the quality of patients' health charts, considering the records for care provided in 4 municipalities with more than 100 thousand inhabitants each in the State of Rio de Janeiro, Brazil, in 2004. This was a cross-sectional study based on primary data collected from direct consultation of patient charts. A two-stage, probabilistic cluster sample was selected from primary care facilities and consultations/patient charts. We checked the completeness of attributes pertaining to the identification of users receiving care and the characteristics of the care itself (weight, blood pressure, Pap tests, and blood glucose) on the charts of women over 19 years of age with hypertension and/or diabetes. User identification showed a low presence of social attributes, and only half of the charts had recorded the opening date. Records of process characteristics in care provided to women with hypertension and diabetes failed to conform to Brazilian Ministry of Health guidelines. Analysis of completeness suggests dubious quality in the continuity of the care provided and difficulties in management practice for primary care and implementation of the Family Health Strategy.

摘要

为了有助于对初级保健进行评估,2004年在巴西里约热内卢州对四个每个都有超过10万居民的市的患者健康记录质量进行了一项研究。这是一项基于从患者病历直接查阅收集的原始数据的横断面研究。从初级保健机构和会诊/患者病历中选取了一个两阶段概率整群样本。我们检查了19岁以上患有高血压和/或糖尿病的女性病历中与接受护理的使用者识别相关的属性以及护理本身的特征(体重、血压、巴氏试验和血糖)的完整性。使用者识别显示社会属性的存在率较低,只有一半的病历记录了开业日期。为高血压和糖尿病女性提供护理的过程特征记录不符合巴西卫生部的指导方针。完整性分析表明所提供护理的连续性质量存疑,初级保健管理实践以及家庭健康战略的实施存在困难。

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