Medical Record Quality Improvement In Patients With Prostate Cancer in referral hospitals in Oncology
Medical Record; Quality Improvement; Checklist; Cancer; Prostate Cancer
In spite of the fact that attention to cancer is a global public health priority, simple failures capable of resonating in the increase of morbidity and mortality of patients still persist nowadays. The Inadequate recording of clinical information leads to the repetition of tests, diagnostic and treatment errors, waste of time and unnecessary costs. This study aims at verifying the effectiveness of a cycle of improvement of medical records in a referral hospital in oncology, by evaluating the level of quality in filling in the patient’s medical records, identifying the quality criteria that presents the greater amount of errors and analyzing the effectiveness of the continuous evaluation cycles that contributed to the improvement of the quality of filling in the patient’s medical records. To this end, ten quality criteria in medical records of patients diagnosed with prostate cancer were examined. From simple random sampling, these criteria were assessed before and after the proposed interventions. Such actions involved administrators and doctors, being directed especially at medical awareness and restructuring of the patient’s medical records via a checklist. In order to identify the level of quality, the point-in-time estimate and confidence interval (95%) of the criteria compliance were selected. In order to prove the effectiveness of interventions, the absolute and relative improvements between the first and the final evaluation, as well as its statistical significance (p < 0.05) were calculated. Compliance rates of 66.4%, on average, and a total of 411 non-conformities, meaning 34.2% of non-compliance were verified in the initial measurement. The associated pathologies criteria, 81.9%, and staging - TNM, 9.5%, stood out as the highest and lowest percentage of non-compliance. In the second measurement, a reduction in the total number of defects of 49.4% was observed. In short, the criteria-based evaluation made possible the identification of quality defects in filling in the surveyed patient’s medical records, which, in turn, directed the proposed interventions. Considering the improvements achieved, it is reasonable to assume that the cycle of improvement was effective in decreasing the defects observed, besides contributing significantly to the progress of quality of the medical record.