Evaluation of the information contained in the referrals of primary care patients in the city of Rio do Sul (SC)

Introduction: The referral process is one of the logistics systems currently in operation, and its function is to link the different levels of health care in a given health care network (HCN). Objective: To evaluate the information contained in the referral guides of patients referred from the prima...

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Detalles Bibliográficos
Autores: Ramos Junior, Eloyve Joaquim, Rocha, Franciani Rodrigues da
Tipo de recurso: artículo
Estado:Versión publicada
Fecha de publicación:2023
País:Brasil
Institución:Sociedade Brasileira de Medicina de Família e Comunidade (SBMFC)
Repositorio:Revista Brasileira de Medicina de Família e Comunidade (Online)
Idioma:portugués
inglés
OAI Identifier:oai:ojs.rbmfc.org.br:article/3358
Acceso en línea:https://rbmfc.org.br/rbmfc/article/view/3358
Access Level:acceso abierto
Palabra clave:Primary Health Care
Referral and Consultation
Health information exchange.
Atenção Primária à Saúde
Encaminhamento e Consulta
Troca de informação em saúde.
Atención Primaria de Salud
Derivación y Consulta
Intercambio de información en salud.
Descripción
Sumario:Introduction: The referral process is one of the logistics systems currently in operation, and its function is to link the different levels of health care in a given health care network (HCN). Objective: To evaluate the information contained in the referral guides of patients referred from the primary care of the HCN in the Brazilian city of Rio de Sul (SC). Methods: An observational, analytical, cross-sectional study was conducted, where the HCN guides were examined from a form containing pre-established variables. The information collected was submitted to descriptive analysis of frequencies, which were represented by n (absolute frequency) and % (percentage). Results: A total of 158 referrals were analyzed, with demographic data being present in 158 (100%), main complaint or reason for referral in 131 (82.9%), description of the main complaint or reason for referral in 82 (51.9 %), description of associated symptoms in 21 (13.3%), past pathological history in 61 (38.6%), list of current medications in 37 (23.4%), allergies in 10 (6.3%), clinically relevant findings in 75 (47.5%), previous investigation results in 45 (28.5%), Prior treatment outline in 42 (26.6%), provisional diagnosis in 75 (47.5%) and declaration of what is expected of the referral in 66 (41.8%). Conclusions: There was a lack of information in HCN referrals when compared to other studies, especially concerning patient historical information, clinical data about the reason for the referral, provisional diagnosis, and declaration of what is expected of the referral. However, encouraging the description of this basic information can be an initial measure to change the current situation.