Gestão documental de prontuários: um estudo de caso no HUSM

Abstract

The problematic of that work of Master’s dissertation in Management of Public Organizations involves the documental management of the patient’ chart and it considers the Form of no Conformity, document created at Santa Maria's University Hospital (HUSM) and enclosed it all of the charts of hospital discharge that presented inconsistencies and they could harm the hospital billing. The objective is to contribute with the documental administration of the charts, considering it more than a support document under the care of health, but also, and with prominence, a document of managerial use. The patient chart is used by a team multi-professional that should register in him all of the information that can be useful and necessary, as much of interned patients as of those assisted in the consultations outpatient. The same is communication instrument among the team of health and of education, because it stores scientific and historical registrations and, also, it possesses value managerial, administrative, financial and legal, in other words, the correct completion not just benefits the patient, but also professionals and institution, avoiding problems ethical, legal and even criminal. HUSM was founded in 1970 and it is reference in health for the 32 cities that are part of 4th Coordenadoria Regional de Saúde (CRS), with thirst in Santa Maria, and, in some specialties, also for to 10th CRS, headquartered in Alegrete, totaling 45 cities and including a population of more than a million inhabitants. Currently, it makes available 403 beds, being 354 of the Unit of Internment and 49 beds of the Unit of Intensive Treatment, besides the 58 clinic rooms, 10 rooms for emergency service, seven rooms of the Surgical Center and two rooms of the Obstetric Center. Daily are scheduled around 800 consultations outpatient in HUSM and the monthly average of internments, in 2017, it was of 1.384. To reach the objective a study of only case it was accomplished, with approach predominantly qualitative. It is treated of an exploratory research, since it also involved documental analysis, bibliographical rising and interviews with people that possess practical experience in relation to the research problem. Also quantitative data were used, looked for in bases of data already existent. The results demonstrate that the flaws in the documentation that is in the charts of HUSM result in repetition of work, damage financial, juridical and administrative to the hospital and in risk of misunderstandings in the service to the patients. It is necessary to become aware the team involved in the patient's documentation that the constant information in the chart not just contemplate in the quality of the rendered attendance, but also in the managerial and administrative activities of the institutions of health. This research brings as a product suggestion of improvements in the documental management related to the charts, in order to minimize damages to HUSM.