Implantação do serviço de arquivo médico estatístico (SAME) da consultoria e auditoria de contas médico-hospitalares (CONSTAT) - gestão de saúde

Abstract

The Medical Archive is responsible for preserving and providing the information of patients' medical records. The Conselho Federal de Medicina (CFM) proposed the Serviço de ArquivoMédico e Estatística (SAME), which is a tool for the management of medical records. The implementation of SAME in healthcare institutions is the best way to provide access to medical records, which might be fundamental to guide the activities of healthcare professionals. This research is applied, with a qualitative, objective-descriptive approach, using field and documentary method. The objective of this study was to implement the SAME at a healthcare company (CONSTAT), seeking to enhance the preservation of patients' medical records and its proper filing, making room for future research in the medical, legal and social sciences. A booklet is presented as a product of the thesis, which aims to raise the awareness of the clinical staff about the importance of medical prescriptions in the patients' medical records, since in the field observation, unreadable notes, erasures, use of acronyms, and missing documents were observed, compromising the healthcare assistance process. The booklet will contribute to the reflections of the clinical staff about the improvement in medical prescriptions in patients' medical records, as well as the activity of the medical chart review committee (CRP).