Qualidade da prescrição e do prontuário em serviço de pronto atendimento de um município de pequeno porte

Abstract

Introduction: Medication therapy aims to treat, cure, or prevent diseases, but it is not without risks. According to the World Health Organization (WHO), medication-related errors are among the most common adverse events and are classified as a severe public health issue. Simultaneously, the quality of medical records is a critical factor for patient safety, directly influencing the quality of care provided. This study aimed to analyze the quality of medical records and prescriptions and investigate the association between these variables and physicians' professional experience. Additionally, the analysis sought to identify prescription errors and correlate them with the quality of medical records.Methodology: This was a cross-sectional study with retrospective data collection from medical records. The sample consisted of 2,350 records systematically and randomly selected from a total of 48,166 patient files from 2022. To determine the sample size, a 2% margin of error and a 95% confidence interval were considered. Records of children and individuals under 18 years old, residents of other municipalities, elective procedure appointments, or records without prescriptions were excluded. Data were collected using a structured form, and variables analyzed included the presence of clinical history, physical examination, diagnostic hypotheses, and treatment plans, as well as legibility and the occurrence of prescription errors. Data were tabulated and analyzed using SPSS software (version 20.0). The analysis included frequencies and percentages for categorical variables and Odds Ratios to identify associations between prescription errors, record quality, and the physicians' years of experience. The study also compared prescription errors among physicians with more than 10 years of practice. This study was approved by the Research Ethics Committee for Human Studies under protocol CAAE: 67754723.0.0000.5148, opinion no. 6.059.877.Results: More than 50% of the analyzed records exhibited significant deficiencies, such as the absence of clinical history (8.8%), illegible descriptions (34.1%), and omission of physical examination findings (63.1%). Additionally, 81.9% of the records lacked documentation of medical treatment plans. Regarding prescriptions, only 4.29% were error-free. The most common errors included inappropriate indications (15.8%) and therapeutic duplication (5%). Errors in writing were frequent, with omissions of drug concentration (62.8%), use of brand names (46.9%), and omission of dosage (30.9%) being the most prevalent. The absence of information in medical records was significantly associated with a higher probability of prescription errors. Furthermore, physicians with more than 10 years of experience were more likely to commit prescription errors, such as therapeutic duplication (OR=8.8) and dose omission (OR=2.2).