标题：Revisão de prontuário como estratégia de ensino-aprendizagem da medicina centrada na pessoa em um ambulatório universitário no município do Rio de Janeiro
期刊名称：Revista Brasileira de Medicina de Família e Comunidade
印刷版ISSN：1809-5909
电子版ISSN：2179-7994
出版年度：2013
卷号：9
期号：30
页码：96-103
语种：Portuguese
出版社：Sociedade Brasileira de Medicina de Família e Comunidade (SBMFC)
摘要：The objective of the present study is to report the experience of the use of a guideline elaborated to guide the review of medical records in an outpatient care unit of a University Hospital in the municipality of Rio de Janeiro. The guideline included open and closed questions regarding patient identification, reason and date of the first appointment, subjective and objective information, evaluation of patients’ health needs, therapeutic plan, entries, continuity of care, and conclusions (diagnostic and therapeutic summary, propositions for improvement of care and learning needs). A medical record was randomly selected, copied and distributed to six voluntary preceptors together with the guideline. Through the analysis of the medical records, it was possible to notice that important information for identification and anamnesis of users was missing or not up-to-date. Concordance was observed in 60% of the closed questions. Heterogeneity was more frequently seen in open questions concerning the understanding about risk, protection, vulnerability, and unrecognized needs of users. All preceptors considered the records incomplete and observed that the entries, which were focused on the diseases, had not been signed by the preceptor. In addition, knowledge regarding patients’ diseases and patient-centered clinical methods were identified as learning necessities. Therefore, the guideline-oriented review of the medical records allowed preceptors to recognize the need for reading medical students’ notes in patients’ records after discussing the cases, pointed out topics for their continuing medical education, and influenced a reflection about their role in the professional development of medical students.
关键词：Medical Records;Primary Health Care;Patient-Centered Care;Education, Medical;Registros Médicos;Atención Primaria de Salud;Atención Dirigida al Paciente;Educación Médica;Registros Médicos;Atenção Primária à Saúde;Assistência Centrada no Paciente;Educação Médica
