Avaliação da comunicação escrita em uma unidade pediátrica de dependentes de ventilação mecânica

Abstract

Introduction: The limitations of the multiprofessional team's written communication trigger a high risk for patient safety, which can cause adverse events and barriers to the dehospitalization of patients with complex chronic conditions. Objective: To evaluate the quality of the multiprofessional team's written communication in a Mechanical Ventilation Dependent Unit of a public pediatric hospital. Methodology: This is a descriptive quantitative research, carried out at the Pediatric Hospital Maria Alice Fernandes, in four stages: 1st) Identification and prioritization of a quality problem; 2nd) Analysis of the causes of the problem; 3rd) Development of criteria to assess the level of quality; 4th) Quality level assessment. Four criteria were selected to assess the quality level, namely: recording the date and time; professional identification; electronic prescription of medicines without acronyms, commercial names and with decimals and zeros; and use of electronic medical records. Results: Of the non-compliances found, 75,0% are concentrated in six criteria stratified by professional categories, which correspond to the recording of the date and time and the use of electronic medical records by nurses (100,0% of non-compliance in both criteria), doctors (91,7% non-compliance in both) and nursing technicians (91,7% noncompliance in recording the date and time and 100,0% in the use of electronic medical records). Physiotherapist professionals did not show any breaches in the date and time recording criteria or in the use of electronic medical records, but they showed 32,3% of non-compliance in identifying professionals in the records, while doctors had 8,3%, nurses, 68,3% and nursing technicians with 86,7%. No problems were found with electronic drug prescriptions. Conclusions: The evaluation of the medical records showed weaknesses in the quality of the records made in the medical records of the study unit, mainly due to the fact that the nursing team does not have access to the electronic medical records for the registration of care. Only the electronic prescription showed good results regarding the fulfillment of quality criteria. In order to achieve improvements in the team's written communication, interventions are essential to expand the use of electronic medical records as a tool to improve the team's record and integration.