Banca de DEFESA: KISNA YASMIN ANDRADE ALVES

Uma banca de DEFESA de DOUTORADO foi cadastrada pelo programa.
DISCENTE : KISNA YASMIN ANDRADE ALVES
DATA : 31/08/2017
HORA: 14:00
LOCAL: Departamento de enfermagem
TÍTULO:

Written communication of health professionals in public hospitals of Rio Grande do Norte state, Brazil.

PALAVRAS-CHAVES:

Patient Safety. Organizational Culture. Hospitals. Health Personnel. Communication. Medical Records.

PÁGINAS: 122
GRANDE ÁREA: Ciências da Saúde
ÁREA: Enfermagem
RESUMO:

The written communication is a tool that contributes to the reduction of damages to the patient, since it allows the unification of the records of the multidisciplinary team and the continuity of the assistance. The written communication is a tool that contributes to the reduction of damages to the patient, since it allows the unification of the records of the multidisciplinary team and the continuity of the assistance. As such, the present study aims to analyze the written communication of health professionals in public hospitals of Rio Grande do Norte state, Brazil. This is a subproject of the wider project entitled “Monitoring the safety indicators of patients in public hospitals of Rio Grande do Norte, Brazil”. It is a cross-sectional study with a prospective design based on the World Health Organization’s “Record review of current in-patients”. The following stages were followed: 1) a scoping review; 2) selection and training of records examiners; 3) testing of records assessment procedures (pilot study); and 4) development of a records review. To that end, we used portions of an instrument containing 10 subtopics and 92 items consisting of professional records and safe drug prescription, use and administration. The review took place between October and December 2016, at three public hospitals in Natal, Rio Grande do Norte state, Brazil, in clinical and surgical wards. Included in the sample were patients hospitalized for at least 10 days. The data were organized in a statistical package and analyzed in a descriptive way, by means of absolute and relative frequency and, Pareto Diagram. The study highlights the ethical principles established by Resolution 466/2012 of the National Health Council. The results highlight that the content of written communication comprises the elements common to the records - patient and professional identification, legible letters, use of acronyms and abbreviations Standardized, absence of erasure and beginning of writings with date and time - and elements specific to each professional category. From the medical records review, the main data on nonconformities were: 1) identification of the patient (headers) - date of birth and affiliation in the identification of the patient; 2) medical evolutions - aspects of the physical examination, personal and family history, habits and living conditions of the patient, intercurrences, laboratory and imaging results in medical evolutions; 3) nursing technician notes - life habits, presence of allergy, identification of the companion, use of medication as to type, general conditions about attitude, mood, locomotion and skin color, nutritional status and patien; 4) essential controls - unit of measurement after the vital signal; 5) nurse's notes - identification of the companion, coloration of the skin, eliminations as to consistency, odor and color; Orientation of the patient/companion; aspects about physical examination, life habits and presence of allergy; 6) common elements of written communication - legible letters, start of records with time and use of abbreviations; and 7) professional identification - category and number in the class council. It is concluded that the written communication of the health professionals in the three hospitals analyzed presents non-conformities in the patient and professional identification data, in the admission and daily records of both doctors and nursing staff. Thus, actions to improve the written communication of the professionals in the hospitals analyzed, as well as to contribute to the discussions about this subject are recommended for effective communication and safe care.

MEMBROS DA BANCA:
Externo à Instituição - ELIZABETH BARICHELLO - UFTM
Externo à Instituição - FRANCIS SOLANGE VIEIRA TOURINHO - UFSC
Interno - 1352508 - MARCOS ANTONIO FERREIRA JUNIOR
Externo ao Programa - 1645299 - MARISE REIS DE FREITAS
Presidente - 1220598 - VIVIANE EUZEBIA PEREIRA SANTOS