<?xml version="1.0" encoding="ISO-8859-1"?><article xmlns:mml="http://www.w3.org/1998/Math/MathML" xmlns:xlink="http://www.w3.org/1999/xlink" xmlns:xsi="http://www.w3.org/2001/XMLSchema-instance">
<front>
<journal-meta>
<journal-id>1981-5271</journal-id>
<journal-title><![CDATA[Revista Brasileira de Educação Médica]]></journal-title>
<abbrev-journal-title><![CDATA[Rev. Bras. Educ. Med.]]></abbrev-journal-title>
<issn>1981-5271</issn>
<publisher>
<publisher-name><![CDATA[Associação Brasileira de Educação Médica]]></publisher-name>
</publisher>
</journal-meta>
<article-meta>
<article-id>S1981-52712020000100204</article-id>
<article-id pub-id-type="doi">10.1590/1981-5271v44.1-20190123</article-id>
<title-group>
<article-title xml:lang="pt"><![CDATA[Avaliação do Prontuário Médico de um Hospital Universitário]]></article-title>
<article-title xml:lang="en"><![CDATA[Evaluation of a University Hospital Medical Record]]></article-title>
</title-group>
<contrib-group>
<contrib contrib-type="author">
<name>
<surname><![CDATA[Garritano]]></surname>
<given-names><![CDATA[Célia Regina de Oliveira]]></given-names>
</name>
<xref ref-type="aff" rid="Aff"/>
</contrib>
<contrib contrib-type="author">
<name>
<surname><![CDATA[Junqueira]]></surname>
<given-names><![CDATA[Felipe Holanda]]></given-names>
</name>
<xref ref-type="aff" rid="Aff"/>
</contrib>
<contrib contrib-type="author">
<name>
<surname><![CDATA[Lorosa]]></surname>
<given-names><![CDATA[Ely Felyppy Soares]]></given-names>
</name>
<xref ref-type="aff" rid="Aff"/>
</contrib>
<contrib contrib-type="author">
<name>
<surname><![CDATA[Fujimoto]]></surname>
<given-names><![CDATA[Mayara Sanae]]></given-names>
</name>
<xref ref-type="aff" rid="Aff"/>
</contrib>
<contrib contrib-type="author">
<name>
<surname><![CDATA[Martins]]></surname>
<given-names><![CDATA[Wallace Hostalacio Avelar]]></given-names>
</name>
<xref ref-type="aff" rid="Aff"/>
</contrib>
</contrib-group>
<aff id="Af1">
<institution><![CDATA[,Universidade Federal do Estado do Rio de Janeiro  ]]></institution>
<addr-line><![CDATA[Rio de Janeiro Rio de Janeiro]]></addr-line>
<country>Brazil</country>
</aff>
<pub-date pub-type="pub">
<day>00</day>
<month>00</month>
<year>2020</year>
</pub-date>
<pub-date pub-type="epub">
<day>00</day>
<month>00</month>
<year>2020</year>
</pub-date>
<volume>44</volume>
<numero>1</numero>
<copyright-statement/>
<copyright-year/>
<self-uri xlink:href="http://educa.fcc.org.br/scielo.php?script=sci_arttext&amp;pid=S1981-52712020000100204&amp;lng=en&amp;nrm=iso"></self-uri><self-uri xlink:href="http://educa.fcc.org.br/scielo.php?script=sci_abstract&amp;pid=S1981-52712020000100204&amp;lng=en&amp;nrm=iso"></self-uri><self-uri xlink:href="http://educa.fcc.org.br/scielo.php?script=sci_pdf&amp;pid=S1981-52712020000100204&amp;lng=en&amp;nrm=iso"></self-uri><abstract abstract-type="short" xml:lang="pt"><p><![CDATA[Resumo:  Introdução:  Este trabalho analisa a qualidade dos prontuários médicos dos pacientes internados no Hospital Universitário Gafrée e Guinle.  Métodos:  Foram selecionados aleatoriamente 100 prontuários da clínica médica e da clínica cirúrgica de pacientes internados nesse Hospital. A análise dos prontuários consistiu na ausência ou presença, dos seguintes tópicos: ficha de identificação do paciente, laudo médico, boletim de internação e alta hospitalar, resumo de internação, evolução médica, evolução da enfermagem, prescrição médica, boletim operatório, boletim da anestesia, laudo do exame histopatológico. Quando havia estes tópicos, verificou-se ainda se eles estavam adequados ou inadequados. Nos prontuários da clínica médica excluíram-se o boletim operatório e da anestesia, laudo do exame histopatológico e os demais tópicos relacionados à cirurgia. Em cada prontuário foi observado se todos os itens citados estavam presentes, preenchidos corretamente, escritos de forma legível, e se havia abreviaturas, siglas e sinais impróprios. No caso de esses itens estarem presentes nos prontuários avaliou-se a adequação ou inadequação deles. Os resultados das ambas as clínicas foram comparados para a análise de qual serviço apresentou um melhor desempenho. Para avaliar o desempenho do hospital todos os itens foram analisados em relação à presença, ausência, adequação ou inadequação e não aplicabilidade. A análise dos dados foi realizada por meio de tabelas e gráficos e a análise estatística pelo teste não paramétrico Mann-Whitney.  Resultados: Durante a pesquisa nem todos os itens foram encontrados e, alguns casos, estavam preenchidos inadequadamente. Além disso, constatou-se a falta de ordenação deles. Do total da amostra analisada, 85,5% estavam legíveis e 32% foram considerados inadequados, sendo 37 prontuários da clínica cirúrgica e 27 da clínica médica. Os resultados dos exames complementares foram encontrados em apenas 55,5% da amostra.  Conclusão: A elaboração dos prontuários no Hospital Universitário Gaffrée e Guinle é deficiente com vários itens incompletos e/ou ausentes.]]></p></abstract>
<abstract abstract-type="short" xml:lang="en"><p><![CDATA[Abstract:  Introduction: To analyze the quality of the medical records of patients admitted to the Gafrée e Guinle University Hospital.  Methods: A total of 100 medical records were randomly selected from the Medical and Surgical Clinics of hospitalized patients at Gaffrée and Guinle University Hospital. The analysis of medical records consisted in the absence or presence and, if present, whether the following items are adequate or inadequate: patient identification file; medical report; hospitalization and discharge reports; hospital admission summary; medical evolution report; nursing evolution report; medical prescriptions; operative report; anesthesia report; histopathological test report. In the Medical Clinic records the operative and anesthesia reports, histopathological test report and other topics related to surgery were excluded. In each medical report it was verified whether the aforementioned items were present, correctly filled out, using legible handwriting, and whether there were inadequate abbreviations, symbols and signs. The results were compared in both clinics to analyze which service showed the best performance. To evaluate the performance of the hospital, all items were analyzed for their presence or absence, whether were adequate or inadequate and not applicable. Data analysis was performed using tables and graphs, and the statistical analysis was performed by the non-parametric Mann-Whitney Test.  Results: Not all items were found nor filled out, in addition to their lack of order. Of the total analyzed sample 85.5% were legible and 32% were considered inadequate, being 37 medical records from the Surgical Clinic and 27 from the Medical Clinic. The results of the additional tests were found in only 55.5% of the sample.  Conclusion: The formulation of Gaffrée and Guinle University Hospital medical records is inadequate, showing multiple incomplete and/or absent items.]]></p></abstract>
<kwd-group>
<kwd lng="pt"><![CDATA[Prontuário médico]]></kwd>
<kwd lng="pt"><![CDATA[Avaliação]]></kwd>
<kwd lng="pt"><![CDATA[Educação médica]]></kwd>
<kwd lng="en"><![CDATA[Medical Record]]></kwd>
<kwd lng="en"><![CDATA[Evaluation]]></kwd>
<kwd lng="en"><![CDATA[Medical Education]]></kwd>
</kwd-group>
</article-meta>
</front><back>
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