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Stud Health Technol Inform ; 266: 136-141, 2019 Aug 08.
Artigo em Inglês | MEDLINE | ID: mdl-31397314


Clinical terminologies play an essential role in enabling semantic interoperability between medical records. However, existing terminologies have several issues that impact data quality, such as content gaps and slow updates. In this study we explore the suitability of existing, community-driven resources, specifically Wikipedia, as a potential source to bootstrap an open clinical terminology, in terms of content coverage. In order to establish the extent of the coverage, a team of expert clinical terminologists manually mapped a clinically-relevant subset of SNOMED CT to Wikipedia articles. The results show that approximately 80% of the concepts are covered by Wikipedia. Most concepts that do not have a direct match in Wikipedia are composable from multiple articles. These findings are encouraging and suggest that it should be possible to bootstrap an open clinical terminology from Wikipedia.

Registros Médicos , Systematized Nomenclature of Medicine
Biochem Med (Zagreb) ; 29(3): 030703, 2019 Oct 15.
Artigo em Inglês | MEDLINE | ID: mdl-31379461


Introduction: Communication of laboratory critical risk results is essential for patient safety, as it allows early decision making. Our aims were: 1) to retrospectively evaluate the current protocol for telephone notification of critical risk results in terms of rates, efficiency and recipient satisfaction, 2) to assess their use in clinical decision making and 3) to suggest alternative tools for a better assessment of notification protocols. Materials and methods: The biochemical critical risk result notifications reported during 12 months by routine and STAT laboratories in a tertiary care hospital were reviewed. Total number of reports, time for the notification and main magnitudes with critical risk results were calculated. The use of notifications in clinical decision making was assessed by reviewing medical records. Satisfaction with the notification protocol was assessed through an online questionnaire to requesting physicians and nurses. Results: Critical result was yielded by 0.1% of total laboratory tests. Median time for notification was 3.2 min (STAT) and 16.9 min (routine). The magnitudes with a greater number of critical results were glucose and potassium for routine analyses, and troponin, sodium for STAT. Most notifications were not reflected in the medical records. Overall mean satisfaction with the protocol was 4.2/5. Conclusion: The results obtained indicate that the current protocol is appropriate. Nevertheless, there are some limitations that hamper the evaluation of the impact on clinical decision making. Alternatives were proposed for a proper and precise evaluation.

Tomada de Decisão Clínica , Análise Química do Sangue , Humanos , Laboratórios Hospitalares , Registros Médicos/normas , Potássio/sangue , Estudos Retrospectivos , Sódio/sangue , Centros de Atenção Terciária , Fatores de Tempo
Stud Health Technol Inform ; 264: 1393-1397, 2019 Aug 21.
Artigo em Inglês | MEDLINE | ID: mdl-31438155


This study used Amazon Mechanical Turk to crowdsource public opinions about sharing medical records for clinical research. The 1,508 valid respondents comprised 58.7% males, 54% without college degrees, 41.5% students or unemployed, and 84.3% under 40 years old. More than 74% were somewhat willing to share de-identified records. Education level, employment status, and gender were identified as significant predictors of willingness to share one's own or one's family's medical records (partially identifiable, completely identifiable, or de-identified). Thematic analysis applied to respondent comments uncovered barriers to sharing, including the inability to track uses and users of their information, potential harm (such as identity theft or healthcare denial), lack of trust, and worries about information misuse. Our study suggests that implementing reliable medical record de-identification and emphasizing trust development are essential to addressing such concerns. Amazon Mechanical Turk proved cost-effective for collecting public opinions with short surveys.

Crowdsourcing , Opinião Pública , Adulto , Feminino , Humanos , Masculino , Registros Médicos , Inquéritos e Questionários , Confiança
J Glob Health ; 9(2): 020411, 2019 Dec.
Artigo em Inglês | MEDLINE | ID: mdl-31360449


Background: Improving the quality of facility-based births is a critical strategy for reducing the high burden of maternal and neonatal mortality and morbidity across all settings. Accurate data on childbirth care is essential for monitoring progress. In northeastern Nigeria, we assessed the validity of childbirth care indicators in a rural primary health care context, as documented by health workers and reported by women at different recall periods. Methods: We compared birth observations (gold standard) to: (i) facility exit interviews with observed women; (ii) household follow-up interviews 9-22 months after childbirth; and (iii) health worker documentation in the maternity register. We calculated sensitivity, specificity, and area under the receiver operating curve (AUC) to determine individual-level reporting accuracy. We calculated the inflation factor (IF) to determine population-level validity. Results: Twenty-five childbirth care indicators were assessed to validate health worker documentation and women's self-reports. During exit interviews, women's recall had high validity (AUC≥0.70 and 0.75

Parto Obstétrico/normas , Documentação/métodos , Atenção Primária à Saúde , Serviços de Saúde Rural , Adolescente , Adulto , Feminino , Humanos , Recém-Nascido , Registros Médicos , Pessoa de Meia-Idade , Nigéria , Gravidez , Reprodutibilidade dos Testes , Autorrelato , Adulto Jovem
N Engl J Med ; 381(1): 9, 2019 Jul 04.
Artigo em Inglês | MEDLINE | ID: mdl-31269363
Rev. Bras. Saúde Mater. Infant. (Online) ; 19(2): 351-361, Apr.-June 2019. tab
Artigo em Inglês | LILACS | ID: biblio-1013144


Abstract Objectives: to relate pregestational nutritional status, maternal age and number of pregnancies to the distribution of macronutrients and micronutrients according to the type of processing offoods consumed by high-risk pregnant women. Methods: a retrospective cross-sectional study was carried out with data from medical records of 200 pregnant women served by a public outpatient clinic in Rio Grande do Sul from 2014 to 2016. Results: the mean percentages of lipids, monounsaturated fatty acids, polyunsaturated fatty acids and sodium intake were higher among ultra-processed foods. There was a significant inverse correlation between maternal age and total calorie intake (p=0.003) and percentage of carbohydrates (p=0.005) and proteins (p=0.037) from ultra-processed foods. There was also a significant association between pregestational nutritional status and total calorie intake (p=0.018) and percentage of carbohydrates (p=0.048) from ultra-processed foods. Conclusions: the mean percentages of lipids, monounsaturated fatty acids, polyunsaturated fatty acids and sodium intake were higher among ultra-processed foods. It was observed that the older the maternal age of high-risk pregnant women, the lower the intake of total calories and percentages of carbohydrates and proteins from ultra-processed foods. It was also observed that pregestational nutritional status was significantly associated with the intake of total calories and percentage of carbohydrates from ultra-processed foods.

Resumo Objetivos: relacionar o estado nutricional pré-gestacional, a idade materna e o número de gestações com a distribuição de macronutrientes e micronutrientes conforme o tipo de processamento dos alimentos consumidos por gestantes de alto risco. Métodos: estudo retrospectivo transversal, realizado a partir de dados de prontuários de 200 gestantes atendidas em um ambulatório público do Rio Grande do Sul, no período de 2014 a 2016. Resultados: a média de consumo em percentuais de lipídios, ácidos graxos monoinsaturados, poli-insaturados e sódio foi maior entre os alimentos ultraprocessados. Observou-se correlação significativamente inversa entre a idade materna e o consumo de calorias totais (p=0,003), percentuais de carboidratos (p=0,005) e proteínas (p=0,037) provenientes de alimentos ultraprocessados. Verificou-se também associação significativa entre o estado nutricional pré-gestacional e o consumo de calorias totais (p=0,018) e percentual de carboidrato (p=0,048) provenientes de alimentos ultraprocessados. Conclusões: a média de consumo em percentuais de lipídios, ácidos graxos monoinsaturados, poli-insaturados e sódio foi maior entre os alimentos ultraprocessados, verificou-se que quanto maior a idade materna da gestante de alto risco, menor é o consumo de calorias totais, percentuais de carboidratos e proteínas, oriundos dos alimentos ultraprocessados e identificou-se também que o estado nutricional pré-gestacional possui associação significativa com o consumo de calorias totais e percentual de carboidrato provenientes de alimentos ultraprocessados.

Humanos , Feminino , Gravidez , Estado Nutricional , Gravidez de Alto Risco , Nutrição Pré-Natal , Comportamento Alimentar , Brasil , Alimentos , Registros Médicos , Estudos Transversais , Estudos Retrospectivos , Idade Materna , Micronutrientes , Saúde Materna
Rev. Bras. Saúde Mater. Infant. (Online) ; 19(2): 375-382, Apr.-June 2019. tab, graf
Artigo em Inglês | LILACS | ID: biblio-1013145


Abstract Objectives: to measure the prevalence of acquiring and evaluating the level of completion of the pregnant women's medical booklet on the occasion of childbirth in Rio Grande, Brazil. Methods: this is a cross-sectional study including all puerperals residing in this municipality in 2007, 2010, 2013 and 2016. The mothers were interviewed at the only two local maternities up to 48 hours after childbirth. The data from the pregnant woman's medical booklet were copied on a standard form. The chi-square test was used to compare proportions. Results: 10,242 pregnant women were included in this study. Of these, 54.8% (CI95%=53.8%-55.7%) had their pregnant woman's medical booklet with them at the time of admission. The completion pattern of the pregnant woman's medical booklet is divided into three groups, namely: with at least 95%: date of the last consultation visit, maternal height and blood pressure verification, uterine height, cardio-fetal heart rate and the Rh factor; 85% or more: date of the last menstruation, qualitative urine test, VDRL and HIV; and less than 30%: performance of clinical breast examination and cytopathology of the uterine cervix. In the private sector, the acquisition of the pregnant woman's medical booklet was 41% lower than at the public sector (62% vs. 44%). Conclusions: the use of the pregnant woman's medical booklet and its completion were lower than expected on several items. Local managers need to work together with the health professionals and these health professionals should work with the mothers to promote the full use of this essential document for the maternal and child's health.

Resumo Objetivos: medir prevalência de posse e avaliar preenchimento da Caderneta da Gestante (CG) por ocasião do parto em Rio Grande, RS. Métodos: estudo transversal incluindo todas as puérperas residentes nesse município em 2007, 2010, 2013 e 2016. As mães foram entrevistadas nas duas únicas maternidades locais em até 48 horas após o parto. As informações da CG foram copiadas em formulário padrão. Na comparação de proporções utilizou-se teste qui-quadrado. Resultados: participaram deste estudo 10.242 parturientes. Destas, 54,8% (IC95%=53,8%-55,7%) portavam CG ao hospitalizar. O padrão de preenchimento da caderneta pode ser dividido em três grupos: com pelo menos 95%: data da última consulta, altura materna e verificação da pressão arterial, altura uterina, batimento cardiofetal e fator Rh; com 85% ou mais: data da última menstruação, exame qualitativo de urina, testagem para VDRL e HIV e com menos de 30%: realização de exame clinico das mamas e citopatológico de colo uterino. No setor privado, a posse da CG foi 41% menor em relação ao setor público (62% versus 44%). Conclusões: a utilização da CG e seu preenchimento para diversos itens estão aquém do esperado. Gestores locais precisam atuar junto aos profissionais de saúde, e estes junto às mães para o uso pleno desse documento essencial à saúde materno-infantil.

Humanos , Cuidado Pré-Natal , Avaliação em Saúde , Registros Médicos , Gestantes , Brasil , Distribuição de Qui-Quadrado , Demografia , Saúde Materno-Infantil , Estudos Transversais , Serviços de Saúde Materna
Rev. urug. enferm ; 14(1): 7-18, jun 2019.
Artigo em Português | LILACS, InstitutionalDB | ID: biblio-1009293


Antes del surgimiento de la psiquiatría, oír voces que otras personas no oyen era considerado una experiencia común. Sin embargo, a partir del siglo XIX, la psiquiatría trajo un nuevo signifi cado para esa experiencia, clasifi cándola como un síntoma característico de diversos trastornos mentales. Sin embargo, en la década de 1980 surge en Holanda el Movimiento Internacional de Oyentes de Voces, que propone la elaboración de nueva interpretación para esa experiencia, permitiendo al (la) oyente nuevas estrategias para comprender y convivir con las voces sin, necesariamente, recurrir a psiquia-tría, pues entiende las voces como parte de la subjetividad humana. Este estudio analizó el registro al respecto de la audición de voces hecho por trabajadores de un servicio de atención psicosocial. La colecta de datos ocurrió entre setiembre de 2017 y mayo de 2018. Fueron analizados 389 prontuarios de usuarios activos en el servicio, de los cuales 181 presentaron registro de audición de voces. Para análisis e interpretación de los datos fue realizada la lectura exhaustiva del material, a partir de la cual emergieron de los temas: a) audición de voces descripta a partir del conocimiento psiquiátrico; b) audición de voces descripta mientras experiencia humana. Los registros de los trabajadores de CAPS evidenciaron que hay una predominancia del conocimiento biomédico, por medio de diferen-tes formas de control del discurso de los usuarios. En ese sentido, es fundamental que el trabajador (a) de la salud mental se movilice en el sentido de promover abordajes terapéuticos que permitan un diálogo emancipatorio, en el sentido de no cronifi car el relato de oír voces en las primeras ex-presiones traídas por los (as) oyentes (as). Cuando bien registrado, el prontuario puede ser utilizado como un instrumento de comunicación entre los integrantes del equipo de salud, y también valorar la experiencia de los usuarios.

Listening to voices that other people do not hear was considered a common experience before the onset of psychiatry. However, from the nineteenth century, psychiatry brought a new meaning to this experience, classifying it as a characteristic symptom of several mental disorders. In the 1980s, however, the International Movement of Voice-hearers was created in the Netherlands, which pro-poses the elaboration of a new interpretation for this experience, allowing the hearer new strategies to understand and coexist with voices without necessarily resorting psychiatry, since it understands voices as part of human subjectivity. ! is study analyzed the record regarding hearing of voices made by the workers of a psychosocial care service. Data collection occurred between September 2017 and May 2018. A total of 389 medical records of active users in the service were analyzed, of which 181 presented voiced hearing records. In order to analyze and interpret the data, a thorough reading of the material was carried out, from which two themes emerged: a) hearing of voices described from psychiatric knowledge; b) hearing of voices described as human experience. ! e records of psychosocial care service workers showed that there is a predominance of biomedical knowledge, through diff erent forms of user discourse control. In this sense, it is fundamental that the mental he-alth worker operate to promote therapeutic approaches that allow an emancipatory dialogue, in the sense of not chronifying the report of hearing voices in the fi rst expressions brought by the hearers. When well recorded, the medical record can be used as an instrument of communication among the members of the health team, and also value the experience of the service users.

Antes do surgimento da psiquiatria, ouvir vozes que outras pessoas não ouvem era considerado uma experiência comum. Porém, a partir do século XIX, a psiquiatria trouxe um novo signifi cado para essa experiência, classifi cando-a como um sintoma característico de diversos transtornos men-tais. No entanto, na década de 1980 surge na Holanda o Movimento Internacional de Ouvidores de Vozes, que propõe a elaboração de uma nova interpretação para essa experiência, permitindo ao (a)ouvinte novas estratégias para compreender e conviver com as vozes sem, necessariamente, recorrer a psiquiatria, pois compreende as vozes como parte da subjetividade humana. Este estudo analisou o registro a respeito da audição de vozes feito pelos trabalhadores de um serviço de atenção psi-cossocial. A coleta de dados ocorreu entre setembro de 2017 e maio de 2018. Foram analisados 389 prontuários de usuários ativos no serviço, dos quais 181 apresentaram registro de audição de vozes. Para análise e interpretação dos dados foi realizada a leitura exaustiva do material, a partir da qual emergiram dois temas: a) audição de vozes descrita a partir do saber psiquiátrico; b) audição de vozes descrita enquanto experiência humana. Os registros dos trabalhadores do CAPS evidenciaram que há uma predominância do saber biomédico, por meio de diferentes formas de controle do discurso dos usuários. Nesse sentido, é fundamental que o trabalhador (a) da saúde mental movimente-se no sentido de promover abordagens terapêuticas que permitam um diálogo emancipatório, no sentido de não cronifi car o relato de ouvir vozes nas primeiras expressões trazidas pelos (as) ouvidores (as). Quando bem registrado, o prontuário pode ser utilizado como um instrumento de comunicação entre os integrantes da equipe de saúde, e também valorizar a experiência dos usuários.

Humanos , Psiquiatria , Registros Médicos , Saúde Mental , Transtornos da Percepção Auditiva , Comunicação em Saúde
BMC Public Health ; 19(1): 668, 2019 May 30.
Artigo em Inglês | MEDLINE | ID: mdl-31146716


BACKGROUND: Accurate and timely data on the health of a population are key for evidence-based decision making at both the policy and programmatic level. In many low-income settings, such data are unavailable or outdated. Using an electronic medical records system, we determined the association between nutritional status and severe illness and mortality among young children presenting to a rural primary health care facility in the Gambia. METHODS: Clinical data collected over five years (2010-2014) on children aged under 60 months making acute visits to a primary health care clinic in the rural Gambian district of Kiang West were retrospectively extracted from the medical records system. Generalised estimating equation models were used to investigate associations between nutritional status and illness severity, accounting for repeat visits, gender, age and access to transport to the clinic. The Population Attributable Fraction (PAF) was used to determine the proportion of severe illness likely attributable to different grades of malnutrition. RESULTS: 3839/5021 (77%) children under 60 months of age living in Kiang West presented acutely to the clinic at least once, yielding 21,278 visits (47% girls, median age 20.2 months (Interquartile Range (IQR) 23.92 months)) and 26,001 diagnoses, 86% being infectious diseases. Severe illness was seen in 4.5% of visits (961/21,278). Wasting was associated with an increased risk of severe illness in a dose-dependent manner, ('WHZ < -1' adjusted Odds Ratio (aOR) 1.68, 95% CI:1.43-1.98, p < 0.001, 'WHZ <-2 and ≥-3' aOR 2.78, 95% CI:2.31-3.36, p < 0.001 and 'WHZ < -3' aOR 7.82, 95% CI:6.40-9.55, p < 0.001) the PAF for wasting (WHZ < -2) was 0.21 (95% CI: 0.18-0.24). Stunting, even in the most severe form (HAZ < -3), was not significantly associated with severe illness (aOR 1.19 95% CI:0.94-1.51) but was associated with a significantly increased risk of death (aOR 6.04 95% CI:1.94-18.78). CONCLUSION: In this population-based cohort of young children in rural Gambia, wasting was associated with disease severity in a dose-dependent manner. Further research is needed into strategies to identify and reach these children with effective interventions to improve their nutritional status.

Estado Nutricional , Atenção Primária à Saúde , Serviços de Saúde Rural , Índice de Gravidade de Doença , Mortalidade da Criança/tendências , Pré-Escolar , Feminino , Gâmbia/epidemiologia , Humanos , Lactente , Masculino , Registros Médicos , Estudos Retrospectivos
Clin Ter ; 170(3): e216-e222, 2019.
Artigo em Inglês | MEDLINE | ID: mdl-31173053


BACKGROUND: Early detection of oral cancer improves survival after treatment and the quality of life. The adoption of standardized methodological protocols of screening has increased the possibilities for early identification and appropriate treatment. The informed consent must be obtained by patients before any treatment and/or surgical procedure. The clinical and surgical details must be discussed with the patient, as well as potential risks and benefits. Consent must be documented in the medical record and consent forms may serve to document the physician's discussion with the patient. OBJECTIVES: all dentists are trained to detect the early signs of oral cancer. The health professional have a key role in identify the early signs of oral cancer in order to plan the treatment and management of the disease. The work aims to provide simple practical information to collect the patient's consent and encouraging him to improve healthy behaviors. MATERIALS AND METHODS: are analyzed the critical issues of clinical practice in order to improve the management of oral cancer. RESULTS AND CONCLUSIONS: Identify effective information approaches documented in the medical record as a tool of close communication between the patient and the physician.

Tomada de Decisão Clínica , Neoplasias Bucais/terapia , Qualidade de Vida , Comunicação , Humanos , Consentimento Livre e Esclarecido , Registros Médicos , Relações Médico-Paciente , Médicos/organização & administração
BMC Health Serv Res ; 19(1): 397, 2019 Jun 20.
Artigo em Inglês | MEDLINE | ID: mdl-31221157


BACKGROUND: Medication charting errors occur often and can be harmful for patients. Interventions to improve charting errors have demonstrated some success particularly if the intervention uses multiple approaches including an education component. The aim of this pilot study was to determine whether a multi-faceted intervention, including education of junior doctors and weekday re-charting could reduce in-hospital charting error. METHODS: Medication charts (n = 579) of all patients admitted to the medical ward of a medium sized regionally-based hospital in Australia over nine months (baseline and during intervention) were inspected for errors. The intervention ran for three months and involved implementation of a National Inpatient Medication Chart targeted error tool with eight targeted charting requirements which was used for visual reminders in the ward and training of junior doctors. In addition, mid-weekly re-charting (MOWER) was performed by a senior and junior doctor team. RESULTS: The mean number of charting requirement errors significantly reduced during the intervention by 26% from 4.6 ± 1.3 to 3.4 ± 1.7 per chart (p < 0.001). Re-chart errors reduced on average by 50% (4.4 ± 1.4 to 2.2 ± 1.7 per chart, p < 0.001) and primary (initial) charts by 20% (4.6 ± 1.3 to 3.7 ± 1.5 per chart, p < 0.001) during the intervention. Failing to provide indication information for a drug, prescriber name, and failing to use generic rather than brand names were the categories with the most errors at baseline and also showed the largest error reductions during the intervention. CONCLUSIONS: A multi-intervention including education of junior doctors, visual reminders and midweek re-charting are effective in reducing the rate of charting errors. We advise that a larger study is now conducted using the same multi-intervention strategy in different ward settings to evaluate feasibility and sustainability of this intervention.

Registros Médicos/normas , Corpo Clínico Hospitalar/educação , Erros de Medicação/prevenção & controle , Austrália , Humanos , Projetos Piloto
Recurso na Internet em Inglês | LIS - Localizador de Informação em Saúde | ID: lis-LISBR1.1-46559


Registries play an important role in research into the cause of cancer, both by providing data on patterns and trends, and in different types of epidemiological study (in particular, in their ability to follow up groups of persons exposed to potential hazard). They comprise an essential element in the planning and monitoring of cancer control strategies, and for identifying priorities in public health.

Neoplasias , Registros Médicos , Sistema de Registros
Medicine (Baltimore) ; 98(20): e15725, 2019 May.
Artigo em Inglês | MEDLINE | ID: mdl-31096527


To investigate the epidemiology trend and characteristics of sepsis-related hospitalizations in Taiwan, and to compare the differences among different severity levels of sepsis.This study is a retrospective national claim database analysis. Hospitalized adult patients with sepsis between 2010 and 2014 were identified from the Two-Million-Sample Longitudinal Health and Welfare Database (LHWD) by the International Classification of Diseases 9th Edition Clinical Modification (ICD-9-CM). The patients were divided into 3 severity groups based on their medical records during hospitalization.The study results showed that in Taiwan, there were 643 new cases of sepsis in 100,000 Taiwanese. The mortality of all septic patients in Taiwan was 287 per 100,000 people, and the case fatality was 29.2%. It was found that the mortality and incidence of sepsis in Taiwan have increased year by year, but there has been no significant change over time. In addition, demographic variation exists in the epidemiology of sepsis. In all the rates investigated, the men's were higher than the women's and the elderly's were higher than the youths'. The analysis results also showed that the respiratory system was the most common site of organ failure in septic patients.The incidence and mortality of any severity level of sepsis were 643, and 287 per 100,000 people in Taiwan, respectively, and the average case fatality was 29.2% during the study period (2010-2014). The respiratory system was the major infected site and site of organ dysfunction, especially in the more severe levels.

Insuficiência Respiratória/epidemiologia , Sepse/epidemiologia , Adolescente , Adulto , Idoso , Feminino , Hospitalização/estatística & dados numéricos , Humanos , Incidência , Masculino , Registros Médicos , Mortalidade , Insuficiência Respiratória/mortalidade , Estudos Retrospectivos , Sepse/mortalidade , Índice de Gravidade de Doença , Taiwan/epidemiologia
Rev Saude Publica ; 53: 41, 2019.
Artigo em Inglês, Espanhol | MEDLINE | ID: mdl-31066819


OBJECTIVE: To determine the frequency of the registry of physical activity and rest recommendations made to pregnant women and to explore their associated factors in a prenatal care program of primary care public institutions in Bucaramanga, Colombia. METHODS: An observational study was conducted. The sampling frame consisted of the medical records of the pregnant women who attended at least one prenatal care program between January 1 and December 31, 2012 (n = 2.932), in 21 primary care health centers. We analyzed sociodemographic variables, prenatal and clinical antecedents, and information related to health personnel and the organization of health centers as possible factors associated with the recommendations of physical activity and rest recorded in the clinical history. Logistic regression models were applied to explore associations with α = 0.10. RESULTS: There was a frequency of 26.1% of PA recommendations and 3.6% of rest recommendation on record, issued by nutrition (97.3%) and medical (86.7%) professionals, respectively. The factors associated with the registration of physical activity recommendations were: being nulliparous pregnant (OR = 1.7), attending more than four Prenatal Care Attention Programs (OR = 2.2), having high or medium obstetric risk in the first prenatal care program (OR = 0.6), and being attended in the western (OR = 0.5) and eastern (OR = 0.2) administrative areas health centers. CONCLUSIONS: The low frequency of physical activity recommendations found in the records makes it necessary to reinforce the management strategies of health centers and strengthen the monitoring and accompaniment to comply with the care protocols. In addition, it is necessary to train health teams on the benefits of physical activity and their proper prescription, considering the multiple benefits derived from their practice on the maternal-fetal health.

Exercício/fisiologia , Gravidez/fisiologia , Cuidado Pré-Natal/métodos , Cuidado Pré-Natal/estatística & dados numéricos , Descanso/fisiologia , Adolescente , Adulto , Antropometria , Colômbia , Feminino , Pessoal de Saúde , Humanos , Registros Médicos , Pessoa de Meia-Idade , Educação Pré-Natal/métodos , Educação Pré-Natal/estatística & dados numéricos , Valores de Referência , Fatores de Risco , Fatores Socioeconômicos , Adulto Jovem
Cad. Ibero Am. Direito Sanit. (Impr.) ; 8(1): 95-109, jan.-mar. 2019.
Artigo em Português | LILACS | ID: biblio-996365


Objetivo: avaliar a condição de sigilo do prontuário médico a partir da perspectiva do direito do paciente, considerando as normativas vigentes no país emanadas do Conselho Federal de Medicina. Metodologia: a pesquisa tem natureza bibliográfica e documental, consubstanciando-se em livros e artigos da área jurídica, em legislação ordinária e resoluções do Conselho Federal de Medicina. Resultados: o prontuário médico é documento complexo, que apresenta caráter informativo e científico. Confidencialidade, sigilo e segurança das informações são princípios observados quando da divulgação das informações contidas no documento. Conclusão: o prontuário médico, seja físico, seja digital, mais do que uma ferramenta de trabalho dos médicos e instituições de saúde, é um direito do paciente e que se encontra acobertado pelo sigilo em respeito à intimidade do paciente. (AU)

Objetivo: evaluar la condición de sigilo del prontuario médico desde la perspectiva del derecho del paciente, considerando las normativas vigentes en el país emanadas del Consejo Federal de Medicina. Metodología: la investigación tiene naturaleza bibliográfica y documental, consubstanciándose en libros y artículos del área jurídica, en legislación ordinaria y resoluciones del Consejo Federal de Medicina. Resultados: el prontuario médico es un documento complejo, que presenta carácter informativo y científico. Confidencialidad, confidencialidad y seguridad de la información son principios observados al divulgar la información contenida en el documento. Conclusión: el prontuario médico, ya sea físico, ya sea digital, más que una herramienta de trabajo de los médicos e instituciones de salud, es un derecho del paciente y que se encuentra encubierto por el sigilo en respeto a la intimidad del paciente. (AU)

Objective: to evaluate the confidentiality condition of the medical record from the perspective of the patient's right, considering the regulations in force in the country emanating from the Federal Medical Council. Methodology: the research has bibliographic and documentary nature, in books and articles of the legal area, in ordinary legislation and resolutions of the Federal Council of Medicine. Results: medical records are complex documents, which are informative and scientific. Confidentiality, confidentiality and security of information are principles observed when disclosing the information contained in the document. Conclusion: Medical records, whether physical or digital, are more than a work tool of physicians and health institutions, it is a patient's right and is covered by secrecy with respect to the patient's intimacy. (AU)

Humanos , Registros Médicos/legislação & jurisprudência , Confidencialidade/ética , Direitos do Paciente
Curr Sports Med Rep ; 18(5): 172-177, 2019 May.
Artigo em Inglês | MEDLINE | ID: mdl-31082890


We describe the implementation of the Athletic Injury Database (AID), a mobile device-based tool for documenting sideline encounters with athletes. Primary measures of the implementation process were: 1) patterns of AID use, 2) nature of sideline encounters captured, and 3) providers' reported satisfaction. Over 2 yr, the AID captured 6237 sideline encounters by athletic trainers and physicians. Most encounters were among athletes participating in football (51%), soccer (15%), and basketball (12%). Knee and ankle injuries were most common. A total of 77% of sports medicine providers were satisfied with the AID. Providers can use information gleaned from a tool like the AID to improve documentation of care provided to athletes.

Traumatismos em Atletas/diagnóstico , Bases de Dados Factuais , Registros Médicos , Aplicativos Móveis , Humanos , Estudos Retrospectivos
Einstein (Sao Paulo) ; 17(2): eAO4583, 2019 May 02.
Artigo em Inglês, Português | MEDLINE | ID: mdl-31066795


OBJECTIVE: To evaluate clinical features and complications in patients with bowel endometriosis submitted to hormonal therapy. METHODS: Retrospective study based on data extracted from medical records of 238 women with recto-sigmoid endometriosis treated between May 2010 and May 2016. RESULTS: Over the course of follow-up, 143 (60.1%) women remained in medical treatment while 95 (39.9%) presented with worsening of pain symptoms or intestinal lesion growth (failure of medical treatment group), with surgical resection performed in 54 cases. Women in the Medical Treatment Group were older (40.5±5.1 years versus 37.3±5.8 years; p<0.0001) and had smaller recto sigmoid lesions (2.1±1.9 versus 3.1±2.2; p=0.008) compared to those who had failed to respond to medical treatment. Similar significant reduction in pain scores for dysmenorrhea, chronic pelvic pain, cyclic dyschezia and dysuria was observed in both groups; however greater reduction in pain scores for dyspareunia was noted in the Surgical Group. Subjective improvement in pain symptoms was also similar between groups (100% versus 98.2%; p=0.18). Major complications rates were higher in the Surgical Group (9.2% versus 0.6%; p=0.001). CONCLUSION: Patients with recto-sigmoid endometriosis who failed to respond to medical treatment were younger and had larger intestinal lesions. Hormonal therapy was equally efficient in improving pain symptoms other than dyspareunia compared to surgery, and was associated with lower complication rates in women with recto-sigmoid endometriosis. Medical treatment should be offered as a first-line therapy for patients with bowel endometriosis. Surgical treatment should be reserved for patients with pain symptoms unresponsive to hormonal therapy, lesion growth or suspected intestinal subocclusion.

Anticoncepcionais Orais Combinados/uso terapêutico , Endometriose/tratamento farmacológico , Dor Pélvica/tratamento farmacológico , Progestinas/uso terapêutico , Doenças Retais/tratamento farmacológico , Doenças do Colo Sigmoide/tratamento farmacológico , Adulto , Dor Crônica , Dismenorreia/tratamento farmacológico , Dispareunia/tratamento farmacológico , Endometriose/cirurgia , Feminino , Seguimentos , Humanos , Registros Médicos , Medição da Dor , Dor Pélvica/cirurgia , Proteínas Recombinantes de Fusão , Doenças Retais/cirurgia , Estudos Retrospectivos , Doenças do Colo Sigmoide/cirurgia , Resultado do Tratamento
Stud Health Technol Inform ; 260: 202-209, 2019.
Artigo em Inglês | MEDLINE | ID: mdl-31118339


Keeping health information confidential is an important aspect of managing health information. This study aimed at determining the performance of health information management departments (HIMD) to identify the policies of these hospitals, their similarities, and differences in their procedures in this respect. Managers of the departments and information disclosure and medical record staff in 22 teaching hospitals were invited to complete a questionnaire regarding their practices in four axes including confidentiality principles, principles of disclosure consent, disclosure information to external and internal users. We found that there are no specific national framework and guidelines for the disclosure of health information. Hospitals are undertaking different ways in this regard. In most cases, patients' consent is not considered necessary for disclosure and only hospital managers' or physicians' consent is sufficient.

Confidencialidade , Gestão da Informação em Saúde , Médicos , Revelação , Humanos , Registros Médicos
Rev. SOBECC ; 24(1): 22-30, jan.-mar.2019.
Artigo em Português | LILACS, BDENF - Enfermagem | ID: biblio-988148


Objetivo: Estimar a adesão ao checklist de cirurgia segura em um hospital de ensino de médio porte. Método: Estudo transversal com uma amostra de 334 pacientes submetidos à cirurgia no ano de 2015. Os dados foram coletados com auxílio de um instrumento baseado no checklist padrão da Organização Mundial da Saúde. A amostra foi descrita por distribuição de frequências. A prevalência de adesão ao checklist foi estimada considerando a presença do instrumento de checagem nos prontuários. A análise bivariada investigou a associação do desfecho com as variáveis independentes. A força dessa associação foi evidenciada por meio da Regressão Logística. Resultados: Verificou-se a existência do checklist em 90,72% dos prontuários. Nenhuma cirurgia apresentou checklist totalmente preenchido. Em nenhum instrumento foi encontrado o preenchimento completo dos três momentos cirúrgicos. A existência do checklist no prontuário foi associada à classificação da cirurgia quanto à urgência (OR=4,3; IC95% 1,88­8,73). Conclusão: Mesmo que o checklist já tenha sido introduzido na prática cirúrgica, os resultados revelam que sua adequada utilização ainda se configura como um grande desafio, podendo comprometer os resultados esperados na segurança cirúrgica

Objective: To estimate adherence to the safe surgery checklist in a medium-sized teaching hospital. Method: A cross-sectional study with a sample of 334 patients submitted to surgery in the year 2015. Data were collected using an instrument based on the World Health Organization's standard checklist. The sample was described by frequency distribution. The prevalence of adherence to the checklist was estimated considering the presence of the instrument of check in the medical records. The bivariate analysis investigated the association of the outcome with the independent variables. The strength of this association was evidenced through Logistic Regression. Results: The checklist was verified in 90.72% of the medical records. No surgery had a fully filled checklist. The complete filling of the three surgical moments was found in no instrument. The existence of the checklist in the medical record was associated with the classification of the surgery for urgency (OR=4.3; 95%CI, 1.88­8.73). Conclusion: Although the checklist has already been introduced in the surgical practice, the results reveal that its adequate use still presents itself as a great challenge, which may compromise the expected results in surgical safety.

Objetivo: Estimar la adhesión al checklist de cirugía segura en un hospital de enseñanza de mediano porte. Método: Estudio transversal con una muestra de 334 pacientes sometidos a la cirugía en el año 2015. Los datos fueron recolectados con ayuda de un instrumento basado en el checklist estándar de la Organización Mundial de la Salud. La muestra fue descrita por distribución de frecuencias. La prevalencia de adhesión al checklist fue estimada considerando la presencia del instrumento de chequeo en los prontuarios. El análisis bivariado investigó la asociación del desenlace con las variables independientes. La fuerza de esta asociación fue evidenciada por medio de la Regresión Logística. Resultados: Se verificó la existencia del checklist en el 90,72% de los prontuarios. Ninguna cirugía presentó checklist totalmente llenado. En ningún instrumento se encontró el llenado completo de los tres momentos quirúrgicos. La existencia del checklist en el prontuario fue asociada a la clasificación de la cirugía en cuanto a la urgencia (OR=4,3, IC95% 1,88­8,73). Conclusión: Aunque el checklist ya se ha introducido en la práctica quirúrgica, los resultados revelan que su adecuada utilización todavía se configura como un gran desafío, pudiendo comprometer los resultados esperados en la seguridad quirúrgica

Humanos , Lista de Checagem , Hospitais de Ensino , Procedimentos Cirúrgicos Operatórios , Registros Médicos , Time Out na Assistência à Saúde