Hospital pharmacist's record in the patient's medical records: Teaching and practice in Brazil
Recording in a clear and orderly way in the patient's medical record enables communication between the multidisciplinary team and facilitates the continuity of care. The objective of this study was to know the opinion and practice of hospital pharmacists and professors in Pharmacy about the per...
| Autores: | , , |
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| Tipo de recurso: | artículo |
| Estado: | Versión publicada |
| Fecha de publicación: | 2022 |
| País: | Brasil |
| Institución: | Universidade Regional do Noroeste do Estado do Rio Grande do Sul (UNIJUI) |
| Repositorio: | Revista Contexto & Saúde (Online) |
| Idioma: | portugués |
| OAI Identifier: | oai:ojs.revistas.unijui.edu.br:article/12466 |
| Acceso en línea: | https://www.revistas.unijui.edu.br/index.php/contextoesaude/article/view/12466 |
| Access Level: | acceso abierto |
| Palabra clave: | Pharmacists Clinical Pharmacy Hospital Pharmacy Service Medical Records Electronic Health Records Farmacêuticos Farmácia Clínica Serviço de Farmácia Hospitalar Registros Médicos Registros Eletrônicos de Saúde |
| Sumario: | Recording in a clear and orderly way in the patient's medical record enables communication between the multidisciplinary team and facilitates the continuity of care. The objective of this study was to know the opinion and practice of hospital pharmacists and professors in Pharmacy about the performance and training related to registration/documentation in the patient's medical record in Brazil. Data collection took place through two electronic questionnaires, directed to pharmacists working in Brazilian hospitals and professors of Pharmacy courses. Forty-seven professors and 248 pharmacists participated in the study. Regarding professors, it was evidenced that: 66% address the theme record in medical records in class with an average workload of 11.55 ±16,14 hours; 42.6% provide students with access to medical records; 100% consider the theme important. Professors who reported more class hours devoted to the topic considered the graduate pharmacist prepared to document in medical records (p-value= <0,05). Among the participating pharmacists: 77.33% have already documented in medical records; 58.06% received formal instruction on the subject; 89.92% stated that pharmacists should document patient care in medical records. Academic background, experience in Clinical Pharmacy, knowledge about legislation and registration methodology were pointed out as determining factors for record in medical records (p-value < 0,05). The pharmacist's documentation in the patient's medical record was considered important by pharmacists who teach and work in the hospital area, so research and continuing education on this topic should be encouraged at all levels of professional training. |
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