Medical records Archives - Revista Brasileira de Ginecologia e Obstetrícia
Summary
Revista Brasileira de Ginecologia e Obstetrícia. 2014;36(6):269-275
DOI 10.1590/S0100-720320140004907
To determine the agreement between the information on pregnant cards and on primary care medical records about prenatal assistance in the city of Vitória, Espírito Santo, Brazil.
A population study of 360 puerperal women living in this city was interviewed at three hospitals where the cards were copied. Prenatal care data were collected by reviewing the medical records at the city health unit. The information was collected, processed, and submitted to Kappa, Adjusted Kappa, and McNemar tests to check agreement and tendency to disagreement between the cards and the medical records.
The levels of agreement within prenatal care were predominantly moderate (Kappa=0.4-0.6). There was a higher tendency to keep records of appointments on the cards (McNemar=22.3; p-value<0.01). Records of supplementation with folic acid and ferrous sulphate were kept more often on the medical records (McNemar=70.8 and 69.8, respectively; p-value<0.01). The tetanus vaccination coverage was about 50%. Clinical and obstetric procedures and laboratory tests were primarily recorded on the card.
The medical records of primary care were underused as a tool for communication among health professionals, highlighting a precarious record keeping. The results suggest that thought be given to guarantee that the minimum procedures established by the Guidelines of Maternal and Infant Health are followed, and also to the importance of clinical record keeping in health services, since there is variation depending on the source of information.
Summary
Revista Brasileira de Ginecologia e Obstetrícia. 2014;36(6):269-275
DOI 10.1590/S0100-720320140004907
To determine the agreement between the information on pregnant cards and on primary care medical records about prenatal assistance in the city of Vitória, Espírito Santo, Brazil.
A population study of 360 puerperal women living in this city was interviewed at three hospitals where the cards were copied. Prenatal care data were collected by reviewing the medical records at the city health unit. The information was collected, processed, and submitted to Kappa, Adjusted Kappa, and McNemar tests to check agreement and tendency to disagreement between the cards and the medical records.
The levels of agreement within prenatal care were predominantly moderate (Kappa=0.4-0.6). There was a higher tendency to keep records of appointments on the cards (McNemar=22.3; p-value<0.01). Records of supplementation with folic acid and ferrous sulphate were kept more often on the medical records (McNemar=70.8 and 69.8, respectively; p-value<0.01). The tetanus vaccination coverage was about 50%. Clinical and obstetric procedures and laboratory tests were primarily recorded on the card.
The medical records of primary care were underused as a tool for communication among health professionals, highlighting a precarious record keeping. The results suggest that thought be given to guarantee that the minimum procedures established by the Guidelines of Maternal and Infant Health are followed, and also to the importance of clinical record keeping in health services, since there is variation depending on the source of information.
Summary
Revista Brasileira de Ginecologia e Obstetrícia. 2012;34(6):259-267
DOI 10.1590/S0100-72032012000600004
PURPOSE: To compare the filling out of the prenatal care card of pregnant women at a school-service and other services, as well as to verify the concordance between these records and verbal information provided by the puerperae. METHODS: A two-stage epidemiological, cross-sectional study was performed with stratified sampling, proportional to number of births. In the first stage, the information recorded on the prenatal care card in the school-service was compared to that recorded in units not linked to higher health education in Recife (PE). In the second stage, the information about prenatal care was collected with a semi-structured questionnaire applied to women during the puerperal period. A total of 262 puerperae older than 19 years, who had a prenatal care card at the time of delivery were included in the study from May to July 2008. Data were analyzed statistically by the χ² test, Student´s t-test or Mann-Whitney test, all one-sided to the right, with the level of significance set at 5%. RESULTS: The information more often recorded on the prenatal care card in the school-service was: schooling (86.5 versus 70.3%; p=0.002), marital status, (83.7 versus 70.9%; p=0.01), weight prior to pregnancy (72.1 versus 46.8%; p<0.001), height (62.5 versus 45.6%; p=0.007), and educational practices (76.9 versus 11.4%; p<0.001) and, at other services, only birth weight <2,500 g (15.4 versus 27.2% at the school-service; p=0.02). There were significant discrepancies between data obtained by verbal information and the prenatal care records of the pregnant women. At the school-service, 40.3% of pregnant women received adequate prenatal care versus 20.3% at other units. CONCLUSIONS: In all services, there was a predominance of recorded information directly related to delivery, while information about actions with preventive characteristics during prenatal care was neglected.
Summary
Revista Brasileira de Ginecologia e Obstetrícia. 2012;34(6):259-267
DOI 10.1590/S0100-72032012000600004
PURPOSE: To compare the filling out of the prenatal care card of pregnant women at a school-service and other services, as well as to verify the concordance between these records and verbal information provided by the puerperae. METHODS: A two-stage epidemiological, cross-sectional study was performed with stratified sampling, proportional to number of births. In the first stage, the information recorded on the prenatal care card in the school-service was compared to that recorded in units not linked to higher health education in Recife (PE). In the second stage, the information about prenatal care was collected with a semi-structured questionnaire applied to women during the puerperal period. A total of 262 puerperae older than 19 years, who had a prenatal care card at the time of delivery were included in the study from May to July 2008. Data were analyzed statistically by the χ² test, Student´s t-test or Mann-Whitney test, all one-sided to the right, with the level of significance set at 5%. RESULTS: The information more often recorded on the prenatal care card in the school-service was: schooling (86.5 versus 70.3%; p=0.002), marital status, (83.7 versus 70.9%; p=0.01), weight prior to pregnancy (72.1 versus 46.8%; p<0.001), height (62.5 versus 45.6%; p=0.007), and educational practices (76.9 versus 11.4%; p<0.001) and, at other services, only birth weight <2,500 g (15.4 versus 27.2% at the school-service; p=0.02). There were significant discrepancies between data obtained by verbal information and the prenatal care records of the pregnant women. At the school-service, 40.3% of pregnant women received adequate prenatal care versus 20.3% at other units. CONCLUSIONS: In all services, there was a predominance of recorded information directly related to delivery, while information about actions with preventive characteristics during prenatal care was neglected.
Summary
Revista Brasileira de Ginecologia e Obstetrícia. 2009;31(10):508-512
DOI 10.1590/S0100-72032009001000007
PURPOSE: to check epidemiological data from a breast diagnostic clinic. METHODS: mammographies from 35,041 patients were studied, within a period of 2 years and 7 months, from 2004 to 2006, 32,049 (91.5%) of them from screening, and 2,992 from symptomatic patients (8.5%). The calculated parameters were: detection rate of the screening patients, percentage of cancer among the symptomatic patients, rate of biopsy indication, percentage of minimal, in situ, and stage 0-1 carcinomas, recall rate, and predictive value of mammographies considered as abnormal and of biopsies' indications in screening patients. RESULTS: 228 diagnoses of breast cancer were made, 111 in screening patients (0.34% detection rate) and 117 in symptomatic patients (3.91% detection rate). The number of biopsies' recommendations among screening patients was 544 (1.7% of those patients). There were 28% of minimal carcinomas, 10% of in situ carcinomas and 93% of stage 0-1 carcinomas among the screening patients. Recall rate was 19%. Positivity of mammographies considered as abnormal (VPP1) was 1.65%. The rate of biopsies' positivity (VPP2) was 21.9%. CONCLUSIONS: this study brings important epidemiological data for the audit of mammographic screening, rare among us. Data have been analyzed as compared to what is recommended by the literature, the detection rate and the percentage of minimal and in situ carcinomas found being comparable to the established values, but with the VPP value lower than the ideal.
Summary
Revista Brasileira de Ginecologia e Obstetrícia. 2009;31(10):508-512
DOI 10.1590/S0100-72032009001000007
PURPOSE: to check epidemiological data from a breast diagnostic clinic. METHODS: mammographies from 35,041 patients were studied, within a period of 2 years and 7 months, from 2004 to 2006, 32,049 (91.5%) of them from screening, and 2,992 from symptomatic patients (8.5%). The calculated parameters were: detection rate of the screening patients, percentage of cancer among the symptomatic patients, rate of biopsy indication, percentage of minimal, in situ, and stage 0-1 carcinomas, recall rate, and predictive value of mammographies considered as abnormal and of biopsies' indications in screening patients. RESULTS: 228 diagnoses of breast cancer were made, 111 in screening patients (0.34% detection rate) and 117 in symptomatic patients (3.91% detection rate). The number of biopsies' recommendations among screening patients was 544 (1.7% of those patients). There were 28% of minimal carcinomas, 10% of in situ carcinomas and 93% of stage 0-1 carcinomas among the screening patients. Recall rate was 19%. Positivity of mammographies considered as abnormal (VPP1) was 1.65%. The rate of biopsies' positivity (VPP2) was 21.9%. CONCLUSIONS: this study brings important epidemiological data for the audit of mammographic screening, rare among us. Data have been analyzed as compared to what is recommended by the literature, the detection rate and the percentage of minimal and in situ carcinomas found being comparable to the established values, but with the VPP value lower than the ideal.