Gestão documental de prontuários médicos em Hospital - Escola da Universidade Federal da Paraíba: o caso do hospital universitário Laureano Wanderley

Abstract

In the health segment, medical records, based on their configuration, are defined by archivology as archival documents. Considering the relevance of this documentation in the hospital context, the object of study refers to the medical records of patients treated at the Lauro Wanderley University Hospital (HULW), located on Campus I of the Federal University of Paraíba (UFPB), in João Pessoa, Paraíba. At the hospital institution of UFPB, document management is the responsibility of the Medical and Statistical Archiving Service (SAME). The study has the general objective of describing how the documentary management of hulw medical records occurs in relation to the production, processing and preservation of physical files related to patient care. As for the methodology, the research can be characterized as a case study, whose nature is qualitative. Regarding the objectives, the research is exploratory and descriptive. For data collection, in addition to observation in locu, we used as research instruments the semi-structured questionnaire and performed photographic records. The participants correspond to the 19 employees assigned to SAME. Archival legislation regulates the mandatory nature of the custody of medical records and should be stored safely for preservation. It should be evidenced that, although the physician is responsible for the preparation of the document, the patient has the right to access the information contained, being the responsibility of the doctor and the hospital institution to custodian, archiving and custody of the medical records. At UFPB HULW, the SAME team is responsible for the custodian of the medical records of the Outpatient Clinic and the patients treated at the hospital, receiving 900 more requests for medical records per day daily and, added to the services of defiling/delivery/receiving and archiving, the sector handles more than 4,000 medical records daily. With regard to the management and collection of documents, same's activity includes the three ages of the archives. Although it does not have a computerized system of production and management of documents, whose medical records are of the physical type, of paper, the data worked out or organized for the preparation of statistical reports on requests, concessions and refusals of access and on the applicants are fundamental to meet the protocalated requests and the legal parameters that require the institution a policy of access to information that ensures the confidentiality of the document, ethical aspects and regimental rules.