Dificuldades no registro de informações nos prontuários de uma unidade básica na percepção de trabalhadores da saúde

Abstract

The record is the most popular means of communication at all levels of care in the health area. Its proper fulfillment is critical to the Good Practices of the Services. Despite its importance, the incomplete filling is still part of the routine of many care units. This study aimed to identify the main difficulties in the registration information in the records of a Basic Health Unit in Natal, in the perception of health workers. The research was cross qualitative. Data were collected through focus group meetings audios records held seventeen professionals responsible for completing records in that unit. Data analysis was performed using the Alceste textual analysis software, with the help of the cause and effect diagram. The results showed that the professionals know the importance of medical records in the care process to health and value information for clinical practice. The difficulties encountered are related to the lack of presentation of documents identifying users through the opening of new records, shortcomings in the records of vital signs and anthropometric data, and the large number of queries. The resolution of the difficulties reported depends on various levels of management, and also run through the improvement of local labor, implementation of continuing education and empowerment of users through a more humanized care.