scholarly journals Utilização do prontuário eletrônico do paciente pela equipe de enfermagem

2020 ◽  
Vol 14 ◽  
Author(s):  
Marielle Maria Oliveira Barros ◽  
Carolinne Kilcia Carvalho Sena Damasceno ◽  
Magda Coeli Vitorino Sales Coêlho ◽  
Juliana Macêdo Magalhães
Keyword(s):  
Medical Record ◽  
Electronic Medical Record ◽  
Nurse Practitioners ◽  
Cross Sectional Study ◽  
Length Of Service ◽  
Microsoft Excel ◽  
Cross Sectional ◽  
El Sistema ◽  
Quantitative Descriptive ◽  
Team Nursing

Objetivo: descrever a utilização do prontuário eletrônico do paciente pela equipe de enfermagem. Método: trata-se de um estudo quantitativo, descritivo, transversal, num hospital privado, com 89 técnicos de enfermagem e 11 enfermeiros. Utilizou-se um questionário para a coleta de dados, processando-os na planilha Microsoft Excel, exportando-os, posteriormente, para o programa IBM SPSS Statistics 20.2. Resultados: predominou-se a faixa etária dos 18 aos 29 anos nas duas classes profissionais e o tempo de serviço variou de 1 a 4 anos. Revela-se que a maioria dos participantes já havia realizado cursos na área da informática e, em relação ao sistema utilizado, afirmaram ser de fácil lembrança, manipulação e acesso, porém, a maior dificuldade relatada foi “o erro no sistema”. Conclusão: reforça-se, pelos resultados, a necessidade de investimentos em relação ao “erro no sistema” ou “falha na conexão”, visto que esse foi o maior problema relatados e está identificado na literatura como desvantagem do prontuário eletrônico. Descritores: Registros Eletrônicos de Saúde; Processos de Enfermagem; Profissionais de Enfermagem; Equipe de Enfermagem; Enfermagem; Informática em Enfermagem.AbstractObjective: to describe the use of the patient's electronic medical record by the nursing staff. Method: this is a quantitative, descriptive, cross-sectional study in a private hospital with 89 nursing technicians and 11 nurses. A data collection questionnaire was used and processed in the Microsoft Excel spreadsheet and then exported to the IBM SPSS Statistics 20.2 program. Results: the age group from 18 to 29 years predominated in both professional classes and the length of service ranged from one to four years. It is revealed that most participants had already taken courses in the area of informatics and, in relation to the system used, said to be easy to remember, manipulate and access, however, the biggest difficulty reported was “the error in the system”. Conclusion: the results reinforce the need for investments in relation to “system error” or “connection failure”, as this was the biggest problem reported and is identified in the literature as a disadvantage of the electronic medical record. Descriptors: Electronic Medical Records; Nursing Process; Nurse Practitioners; Nursing, Team; Nursing; Nursing Informatics. ResumenObjetivo: describir el uso del historial médico electrónico del paciente por parte del personal de enfermería. Método: este es un estudio cuantitativo, descriptivo, transversal en un hospital privado con 89 técnicos de enfermería y 11 enfermeros. Se utilizó y se procesó un cuestionario de recopilación de datos en la hoja de cálculo de Microsoft Excel y luego se exportó al programa IBM SPSS Statistics 20.2. Resultados: el grupo de edad de 18 a 29 años predominó en ambas clases profesionales y la duración del servicio varió de 1 a 4 años. Se revela que la mayoría de los participantes ya habían tomado cursos en el área de tecnología de la información y, en relación con el sistema utilizado, se dice que es fácil de recordar, manipular y acceder, sin embargo, la mayor dificultad reportada fue "el error en el sistema". Conclusión: los resultados refuerzan la necesidad de inversiones en relación con "error del sistema" o "falla de conexión", ya que este fue el mayor problema reportado y se identifica en la literatura como una desventaja del historial clínico electrónico. Descriptores: Registros Electrónicos de Salud; Proceso de Enfermería; Enfermeras Practicantes; Grupo de Enfermería; Enfermería; Informática Aplicada a la Enfermería.

scholarly journals Perfil dos diagnósticos de enfermagem de fumicultores

2019 ◽  
Vol 13 ◽  
Author(s):  
Naise de Moura Dantas ◽  
Alexandre Wendell Araujo Moura ◽  
Andreivna Kharenine Serbim ◽  
Cristiane Araujo Nascimento ◽  
Ana Caroline Melo dos Santos ◽  
...  
Keyword(s):  
Elementary Education ◽  
Family Health ◽  
Cross Sectional Study ◽  
Microsoft Excel ◽  
Cross Sectional ◽  
Safety Standards ◽  
The North ◽  
Nursing Diagnosis ◽  
Quantitative Descriptive ◽  
Nursing Diagnoses

RESUMO Objetivo: descrever os diagnósticos de Enfermagem segundo a taxonomia da American Nursing Diagnosis Association II.  Método: trata-se de estudo quantitativo, descritivo, transversal, com 51 produtores de tabaco expostos a agroquímicos que viviam na comunidade rural. Coletaram-se os dados por meio das consultas de Enfermagem. Tabularam-se os dados n Programa Microsoft Excel 2010, posteriormente inseridos no banco de dados utilizando o programa SPSS, versão 22.0, for Windows, e submetidos à revisão e análise estatística. Apresentaram-se os resultados em tabelas. Resultados: verificou-se, por meio das consultas de Enfermagem, que a maioria era do sexo feminino, tinha ensino fundamental incompleto e não praticava nenhum tipo de exercício físico. Acrescenta-se, além disso, que eles desconheciam os riscos para a saúde colocados pelos pesticidas e negligenciaram os padrões de segurança recomendados para o manuseio desses produtos. Conclusão: pode-se observar, a partir deste estudo, que o enfermeiro tem um papel importante no cuidado e na educação, nos diversos espaços de promoção, prevenção e manutenção do cuidado em saúde. Descritores: Enfermagem; Diagnósticos de Enfermagem; Estratégia Saúde da Família; Área Rural; Saúde Pública; Saúde do Trabalhador.ABSTRACT Objective: to describe Nursing diagnoses according to the Taxonomy II proposed by the North American Nursing Diagnosis Association. Method: this is a quantitative, descriptive, cross-sectional study conducted with co plantations. The research was carried out with 51 tobacco growers exposed to agrochemicals living in the rural community. The data were collected through nursing consultations. The data collected were tabulated in the Microsoft Excel 2010 software and later entered into a database using the SPSS software version 22.0, for Windows, and subjected to statistical review and analysis. The results were presented in tables. Results: the Nursing consultations revealed that the majority of the farm workers were females, had incomplete elementary education, and did not practice any type of physical exercise. In addition, they were unaware of the health risks posed by pesticides and neglected the recommended safety standards for the handling of these products. Conclusion: it was observed in this study that nurses have an important role in care and education, in the various spaces of promotion, prevention and maintenance of health care. Descriptors: Nursing; Nursing Diagnoses; Family Health Strategy; Rural Area; Public Health; Occupational Health.RESUMEN Objetivo: se buscó describir los diagnósticos de Enfermería según la taxonomía de la American Nursing Diagnosis Association II. Método: se trata de un estudio cuantitativo, descriptivo, transversal, realizado con 51 productores de tabaco expuestos a agroquímicos que vivían en la comunidad rural. Se recogieron los datos por medio de las consultas de Enfermería. Se tabularon los datos recogidos en el programa Microsoft Excel 2010, posteriormente inseridos en el banco de datos utilizando el programa SPSS, versión 22.0, for Windows, y sometidos a la revisión y análisis estadística. Se presentaron los resultados en tablas. Resultados: se verificó, por medio de las consultas de Enfermería, que la mayoría era del sexo femenino, tenía enseñanza primaria incompleta y no praticaba ningún tipo de ejercicio físico. Además de eso, ellos desconocen los riesgos para la salud colocados por los pesticidas y negligenciaron los patrones de seguridad recomendados para el manoseo de esos productos. Conclusión: se puede observar, a partir de este estudio, que el enfermero tiene un papel importante en el cuidado y en la educación, en los diversos espacios de promoción, prevención y mantenimiento del cuidado en salud. Descriptores: Enfermería; Diagnósticos de Enfermería; Estrategia Salud de la Familia; Zona Rural; Salud Pública; Salud Laboral.

scholarly journals Perfil epidemiológico do vômito em trauma cranioencefálico leve infantil

2019 ◽  
Vol 13 ◽  
Author(s):  
Edina De Oliveira Lima ◽  
Elizabeth De Souza Amorim ◽  
Sílvia Elizabeth Gomes de Medeiros ◽  
Poliana Milanez Rodrigues de Mendonça
Keyword(s):  
Brain Injuries ◽  
Cross Sectional Study ◽  
Microsoft Excel ◽  
Cross Sectional ◽  
Documentary Analysis ◽  
Reference Hospital ◽  
Quantitative Descriptive ◽  
One Year ◽  
Epidemiological Profile ◽  
New Research

RESUMOObjetivo: analisar o perfil epidemiológico do vômito em caso de Trauma Cranioencefálico leve infantil em um Hospital de Referência.  Método: trata-se de estudo quantitativo, descritivo, transversal, com análise documental em prontuários, determinando-se a amostra por conveniência. Dividiram-se, na análise das variáveis, os dados em: 1ª parte voltada aos dados socioeconômicos e a 2ª parte, aos dados do trauma com o vômito, por meio de um questionário. Armazenaram-se e analisaram-se os dados com o auxílio do software Microsoft Excel 2013, e se apresentaram em forma de tabelas. Resultados: obteve-se o total de 121 pacientes, com prevalência masculina, de um ano de idade e com queda. Encontrou-se o total de 379 vômitos, apresentando um vômito, no mínimo. Informa-se que não foram utilizados antieméticos em 83,47% dos casos. Conclusão: constataram-se a falta de administração de antieméticos e a escassez de estudos sobre vômito como sintoma principal do TCE leve infantil, proporcionando novas pesquisas. Descritores: Traumatismos Craniocerebrais; Vômito; Pré-Escolar; Cuidado da Criança; Perfil de Saúde; Antieméticos.ABSTRACTObjective: to analyze the epidemiological profile of vomiting in case of mild Cranioencephalic Infant Trauma in a Reference Hospital. Method: this is a quantitative, descriptive, cross-sectional study with documentary analysis in medical records, determining the sample for convenience. In the analysis of the variables, the data were divided into: 1st part focused on the socioeconomic data and the 2nd part, on the data of the trauma with the vomit, through a questionnaire. The data was stored and analyzed using Microsoft Excel 2013 software, and presented in the form of tables. Results: a total of 121 patients, with male prevalence, one year old and with fall were obtained. A total of 379 vomiting were found, with at least one vomit. It is reported that no antiemetics were used in 83.47% of the cases. Conclusion: there was a lack of administration of antiemetics and a lack of studies on vomiting as the main symptom of mild childhood TBI, providing new research. Descriptors: Head and Brain Injuries; Vomiting; Preschool; Child Care; Health Profile; Antiemetics.RESUMEN Objetivo: analizar el perfil epidemiológico del vómito en caso de Trauma Craneoencefálico leve infantil en un Hospital de Referencia. Método: se trata de un estudio cuantitativo, descriptivo, transversal, con análisis documental en prontuarios, determinándose la muestra por conveniencia. Se dividieron en el análisis de las variables los datos en: 1ª parte dirigida a los datos socioeconómicos y la segunda parte, a los datos del trauma con el vómito, por medio de un cuestionario. Se almacenaron y analizaron los datos con la ayuda del software Microsoft Excel 2013, y se presentaron en forma de tablas. Resultados: se obtuvo el total de 121 pacientes, con prevalencia masculina, de un año de edad y con caída. Se encontró el total de 379 vómitos, presentando un vómito, como mínimo. Se informa que no se utilizaron antieméticos en el 83,47% de los casos. Conclusión: se constató la falta de administración de antieméticos y la escasez de estudios sobre vómito como síntoma principal del TCE leve þ, proporcionando nuevas investigaciones. Descriptores: Traumatismos Craneocerebrales; Vómitos; Preescolar; Cuidado del Niño; Perfil de Salud; Antieméticos.

scholarly journals Epidemiologia da mortalidade por causas externas no período de 2004 a 2013

2018 ◽  
Vol 12 (3) ◽  
pp. 716 ◽  
Author(s):  
Lucas Corrêa Preis ◽  
Greice Lessa ◽  
Francis Solange Vieira Tourinho ◽  
José Luís Guedes dos Santos
Keyword(s):  
Health Management ◽  
Progressive Increase ◽  
Cross Sectional Study ◽  
Cross Sectional ◽  
Unified Health System ◽  
El Sistema ◽  
System Data ◽  
External Causes ◽  
Quantitative Descriptive ◽  
Epidemiological Profile

RESUMOObjetivo: analisar o perfil epidemiológico da mortalidade por causas externas na Região Sul do Brasil, no período de 2004 a 2013. Método: estudo quantitativo, descritivo, exploratório, retrospectivo e transversal, desenvolvido a partir dos dados disponibilizados pelo Sistema de Informações sobre Mortalidade. A coleta de dados foi realizada no site do Departamento de Informática do Sistema Único de Saúde utilizando-se um formulário. A amostra foi constituída pelos 1.737.448 registros de óbitos decorrentes de causas externas de morbidade e mortalidade e a análise foi realizada por meio de estatística descritiva. Resultados: os dados mostraram que a maior parte dos óbitos foi de indivíduos do sexo masculino (56,94%), com idade entre 20 e 39 anos (42,73%), de cor branca (86,21%), solteiros (57,81%), com até sete anos de estudos (40,39%) e o hospital como principal local de ocorrência (40,70%). Conclusão: constatou-se aumento progressivo do número de óbitos decorrentes de causas externas. Os resultados obtidos poderão fornecer subsídios para a formulação de políticas públicas eficazes na busca pela diminuição dos índices de mortes. Descritores: Mortalidade; Morbidade; Causas Externas; Sistemas de Informação; Epidemiologia; Gestão em Saúde. ABSTRACT Objective: to analyze the epidemiological profile of mortality due to external causes in the Southern Region of Brazil from 2004 to 2013. Method: this is a quantitative, descriptive, exploratory, retrospective and cross-sectional study, based on data provided by the Mortality Information System. Data collection was performed on the website of the Department of Information Technology of the Unified Health System using a form. The sample consisted of 1,737,448 records of deaths due to external causes of morbidity and mortality, and the analysis was performed using descriptive statistics. Results: data showed that most deaths were male (56.94%), aged 20 to 39 (42.73%), white (86.21%), unmarried (57.81%), with up to seven years of school (40.39%) and the hospital as the main place of occurrence (40.70%). Conclusion: there was a progressive increase in the number of deaths due to external causes. The results obtained may provide subsidies for the formulation of effective public policies in the search for a decrease in death rates. Descriptors: Mortality; Morbidity; External Causes; Information Systems; Epidemiology; Health Management. RESUMEN Objetivo: analizar el perfil epidemiológico de la mortalidad por causas externas en la Región Sur de Brasil en el período de 2004 a 2013. Método: estudio cuantitativo, descriptivo, exploratorio, retrospectivo y transversal, desarrollado a partir de los dados disponibilizados por el Sistema de Informaciones sobre Mortalidad. La recolección de datos fue realizada en el site del Departamento de Informática del Sistema Único de Salud utilizando un formulario. La muestra fue constituida por los 1.737.448 registros de óbitos decurrentes de causas externas de morbilidad y mortalidad y el análisis fue realizado por medio de estadística descriptiva. Resultados: los datos mostraron que la mayor parte de los óbitos fue de individuos del sexo masculino (56,94%), con edad entre los 20 a los 39 años (42,73%), de color blanca (86,21%), solteros (57,81%), con hasta siete años de estudios (40,39%) y el hospital como principal local de ocurrencia (40,70%). Conclusión: se constató aumento progresivo del número de óbitos decurrentes de causas externas. Los resultados obtenidos poderán fornecer subsidios para la formulación de políticas públicas eficaces en la búsqueda por la diminución de los índices de muertes. Descriptores: Mortalidad; Morbilidad; Causas Externas; Sistemas de Información; Epidemiología; Gestión en Salud. 

scholarly journals Physicians’ Attitude towards Electronic Medical Record Systems: An Input for Future Implementers

2021 ◽  
Vol 2021 ◽  
pp. 1-9
Author(s):  
Mulugeta Hayelom Kalayou ◽  
Berhanu Fikadie Endehabtu ◽  
Habtamu Alganeh Guadie ◽  
Zeleke Abebaw ◽  
Kassahun Dessie ◽  
...  
Keyword(s):  
Qualitative Study ◽  
Medical Record ◽  
Electronic Medical Record ◽  
Computer Literacy ◽  
Health Care Quality ◽  
Cross Sectional Study ◽  
Study Data ◽  
Care Quality ◽  
Cross Sectional ◽  
Improve Health Care Quality

Background. Electronic medical record (EMR) systems offer the potential to improve health care quality by allowing physicians real-time access to patient healthcare information. The endorsement and usage of EMRs by physicians have a significant influence on other user groups in the healthcare system. As a result, the purpose of this study was to examine physicians’ attitudes regarding EMRs and identify the elements that may influence their attitudes. Method. An institutional-based cross-sectional study design supplemented with a qualitative study was conducted from March 1 to April 30, 2018, among a total of 403 physicians. A self-administered questionnaire was used to collect quantitative data. The validity of the prediction bounds for the dependent variable and the validity of the confidence intervals and P values for the parameters were measured with a value of less than 0.05 and 95 percent of confidence interval. For the supplementary qualitative study, data were collected using semistructured in-depth interviews from 11 key informants, and the data were analyzed using thematic analysis. Result. Physicians’ computer literacy (CI: 0.264, 0.713; P : 0001) and computer access at work (CI: 0.141, 0.533, P : 0.001) were shown to be favorable predictors of their attitude towards EMR system adoption. Another conclusion from this study was the inverse relationship between physicians’ prior EMR experience and their attitude about the system (CI: -0.517, -0.121; P : 0.002). Conclusion. According to the findings of this study, physicians’ attitudes regarding EMR were found moderate in the studied region. There was a favorable relationship between computer ownership, computer literacy, lack of EMR experience, participation in EMR training, and attitude towards EMR. Improving the aforementioned elements is critical to improving physicians’ attitudes regarding EMR.

scholarly journals Religion: Interrelationships and Opinions in Children and Adolescents. Interaction between Age and Beliefs

Religions ◽  
2021 ◽  
Vol 12 (5) ◽  
pp. 357
Author(s):  
Rafael López Cordero ◽  
Francisca Ruiz Garzón ◽  
Lourdes Medina Martínez ◽  
María del Carmen Olmos-Gómez
Keyword(s):  
Children And Adolescents ◽  
Current Trend ◽  
Age Groups ◽  
Cross Sectional Study ◽  
Experimental Methodology ◽  
Cross Sectional ◽  
Younger Age ◽  
Religious Issue ◽  
Quasi Experimental ◽  
Quantitative Descriptive

The current trend of secularization seems to be leading to a gradual withdrawal of religion from public spaces. However, in an increasingly internationalized world, it is becoming more and more important to study the roles of religion and religiosity and their potential in relation to dialogue and social conflicts and tensions. Education is a vital field within which to address this religious issue and create an educational dialogue in order to promote coexistence. By following a quantitative, descriptive, cross-sectional study, based on a quasi-experimental methodology with a social–analytical character, our aim is to assess the existing connections between religion, interrelation and opinion in Spanish children and adolescents. Special attention is paid to the interaction between age and beliefs. We carried out our study with the use of a questionnaire distributed to eleven secondary schools, with students aged between 11 and 16 years old, in three regions of southern Spain (Andalusia, Ceuta, and Melilla) characterized by high religious diversity and multiculturalism. The multivariate analysis carried out in this study identifies the effects of variance on the influence of age and religion, highlighting the interaction between the two. It is observed that the youngest students are those who express their opinions about religion the least, while those belonging to younger age groups and majority religions are those who express a greater religious coexistence, with Muslims externalizing their religious condition the most.

scholarly journals Medication Errors in Adolescents Using Asthma Controller Medications

2020 ◽  
Vol 7 ◽  
pp. 2333794X2098134
Author(s):  
Henry Clark ◽  
Delesha Carpenter ◽  
Kathleen Walsh ◽  
Scott A. Davis ◽  
Nacire Garcia ◽  
...  
Keyword(s):  
Medical Record ◽  
Medication Errors ◽  
Medication Use ◽  
Persistent Asthma ◽  
Cross Sectional Study ◽  
Asthma Medication ◽  
Sectional Study ◽  
Cross Sectional ◽  
Controller Medication ◽  
Controller Medications

The purpose of this study was to describe the number and types of errors that adolescents and caregivers report making when using asthma controller medications. A total of 319 adolescents ages 11 to 17 with persistent asthma and their caregivers participated in this cross-sectional study. Adolescent and caregiver reports of asthma medication use were compared to the prescribed directions in the medical record. An error was defined as discrepancies between reported use and the prescribed directions. About 38% of adolescents reported 1 error in using asthma controller medications, 16% reported 2 errors, and 5% reported 3 or more errors. About 42% of caregivers reported 1 error in adolescents using asthma controller medications, 14% reported 2 errors, while 6% reported 3 or more errors. The type of error most frequently reported by both was not taking the medication at all. Providers should ask open-ended questions of adolescents with asthma during visits so they can detect and educate families on how to overcome errors in taking controller medication use.

CHILDREN'S AWARENESS OF MEDICINES, DRUG COMPLIANCE AND HEALTH PROTECTION DURING COVID 19 PANDEMIC: A DETAILED CROSS SECTIONAL STUDY

2021 ◽  
pp. 20-24
Author(s):  
Radhika Vijay
Keyword(s):  
Cross Sectional Study ◽  
Sectional Study ◽  
Great Role ◽  
Drug Compliance ◽  
Online Questionnaire ◽  
Microsoft Excel ◽  
Cross Sectional ◽  
North West ◽  
Adult Lives ◽  
Prevention Of Infections

OBJECTIVES: Nobody is refrained from the use of medications in today's times, not even kids,The objective of this study is to focus on the knowledge and awareness level, perception, of children of primary and secondary grade towards medicines , prevention of Infections and Diseases and drug compliance. This descriptive, cross sectional observational study was done METHODS: amongst the kids of North West Rajasthan ,India from August 2020 to October 2020 via an online questionnaire . A sample size of 100 kids , 50 each from Primary and Secondary grade was chosen for the study. The data was entered in Microsoft Excel and was statistically analysed. Results are outcomes of various RESULTS: questions put up to conduct detailed analysis of kids' awareness and medicinal knowledge, drug preferences, factors inuencing and attitude related to hygiene, safety and protection from Covid 19 infection. Kids are the young budding phys CONCLUSION: icians and their childhood beliefs and perceptions might affect their behaviour and decisions in adult lives. Parents and schools can play a great role through educational programs . It's well said, “Children are like wet cement, whatever falls on them, leaves an impression.”

scholarly journals Violência de gênero, viés social e drogas

2020 ◽  
Vol 14 ◽  
Author(s):  
Vanessa Ferreira de Almeida Piuchi ◽  
Claudia Barleta ◽  
Juliana Monte Real
Keyword(s):  
Black Women ◽  
Care Center ◽  
Psychosocial Care ◽  
Cross Sectional Study ◽  
Gender Violence ◽  
Cross Sectional ◽  
Salud Mental ◽  
Las Mujeres ◽  
Quantitative Descriptive ◽  
High Level

Objetivo: analisar a violência de gênero sofrida pelas mulheres usuárias do Centro de Atenção Psicossocial Álcool e Drogas. Método: trata-se de um estudo quantitativo, descritivo, de corte transversal, com 30 mulheres atendidas pelo CAPS AD, que estavam ativas no sistema Registro das Ações Ambulatoriais de Saúde e responderam a um questionário estruturado. Analisaram-se os dados empregando a estatística não paramétrica. Resultados: apresenta-se, pelas mulheres pesquisadas, índice de violência elevada em relação à média nacional. Detalha-se que os fatores que apareceram como agravantes foram raça/cor, escolaridade e moradia, as maiores vítimas: mulheres negras e de escolaridade baixa. Conclusão: agrava-se, pelos fatores sociais, a violência praticada contra as mulheres pesquisadas. Mostra-se, para os agravantes, a necessidade de se incluir discussões nas políticas de combate à violência. Revela-se que o número de denúncia é baixo, assim como a procura por serviços de saúde. Descritores: Violência de Gênero; Saúde mental; Uso de Drogas; CAPS AD; Saúde Pública; Violência contra Mulheres.AbstractObjective: to analyze the gender violence suffered by women, users of the Psychosocial Care Center for Alcohol and Drugs. Method: this is a quantitative, descriptive, cross-sectional study of 30 women treated at CAPS AD, who were active in the Outpatient Health Actions Registry system and answered a structured questionnaire. Data was analyzed using nonparametric statistics. Results: the surveyed women presented a high level of violence in relation to the national average. It is noted that the factors that appeared as aggravating factors were race / color, education and housing, the biggest victims: black women and low education. Conclusion: the violence against women surveyed is aggravated by social factors. For the aggravating factors, the need to include discussions in the policies to combat violence is shown. The number of complaints is low, as is the demand for health services. Descriptors: Gender Violence; Mental Health; Drug Use; CAPS AD; Public Health; Violence Against Women.ResumenObjetivo: analizar la violencia de género que sufren las mujeres usuarias del Centro de Atención Psicosocial de Alcohol y Drogas. Método: este es un estudio cuantitativo, descriptivo, transversal con 30 mujeres atendidas por CAPS AD, que estaban activas en el sistema de Registro de Acciones de Salud Ambulatoria y respondieron un cuestionario estructurado. Los datos se analizaron mediante la estadística no paramétrica. Resultados: las mujeres encuestadas presentaron un alto nivel de violencia en relación con el promedio nacional. Cabe señalar que los factores que aparecieron como factores agravantes fueron la raza / color, la educación y la vivienda, las principales víctimas: las mujeres negras y de baja educación. Conclusión: la violencia contra las mujeres encuestadas se ve agravada por factores sociales. Para los factores agravantes, se muestra la necesidad de incluir discusiones en las políticas para combatir la violencia. El número de quejas es bajo, al igual que la demanda de servicios de salud. Descriptores: Violencia de Género; Salud Mental; Uso de Drogas; CAPS AD; Salud Pública; Violencia Contra la Mujer.

scholarly journals QUANTITATIVE EVALUATION OF MEDICAL RECORD DOCUMENTATION IN IMAM REZA HOSPITAL, MASHHAD, IRAN

2017 ◽  
Vol 1 (4) ◽  
pp. 98-99
Author(s):  
Zahra Mazloum khorasani ◽  
Mahmood Tara ◽  
Kobra Etminani ◽  
Zohre Moosavi ◽  
Zahra Ebnehoseini
Keyword(s):  
Medical Record ◽  
Medical Records ◽  
Qualitative Evaluation ◽  
Cross Sectional Study ◽  
Diabetic Patients ◽  
Cross Sectional ◽  
Accurate Treatment ◽  
Diabetes Center ◽  
Data Elements ◽  
Medical Record Documentation

Introduction: Diabetes is the most common endocrine disease. Given the importance of medical record documentation for diabetic patients and its significant impact on accurate treatment process, as well as early diagnosis and treatment of acute and chronic complications, this study aimed to qualitatively evaluate medical record documentation of diabetic patients. Methods: This descriptive and cross-sectional study was conducted on all medical records of diabetic patients (1200 cases) in the comprehensive Diabetes Center of Imam Reza Hospital. A checklist was prepared according to the main sectors and their sub-data elements to conduct a qualitative evaluation on documentation of medical records of diabetic patients.  Descriptive statistics were used to report the results. Results: In this study, 1200 (710 women and 490 men) cases were evaluated. Mean documentation of main sectors of diabetic patients’ records were as follows: 49% demographic characteristics, 14% patient referral, 4% diagnosis, 50% lab tests, 25% diabetes medications,13% nephropathy screening test, 10% diabetic neuropathy, 41% specialty and subspecialty consultations and internal medicine physicians visits did not complete for all the patients. Conclusion: According to the results of this study, qualitative evaluation of medical record documentation of diabetic patients Showed poor documentation in this regard. It is suggested that results of this study be accessible to physicians of healthcare centers to take a positive step toward improved documentation of medical records. In addition, it seems necessary to modify diabetic medical records.

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