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Authors
Advisor(s)
Abstract(s)
Introdução: O registo de todos os eventos clínicos, morbilidades e co morbilidades quer
durante o internamento, quer em ambulatório permite uma melhor prevenção e tratamento
das doenças crónicas. A presença de informação válida nos registos médicos e de enfermagem
sobre os factores de risco cardiovascular e de doença crónica é importante para a redução do
enorme impacto e custos socioeconómicos actualmente associados às doenças crónicas. O
principal objectivo desta investigação é avaliar a prática clínica no que diz respeito ao registo
do tabagismo e de outros factores de risco cardiovascular e de doença crónica pelos
profissionais de saúde (médicos e enfermeiros) durante o internamento no Centro Hospitalar
Cova da Beira.
Metodologia: Estudo observacional, transversal e descritivo. Foram analisados os processos
clínicos dos indivíduos internados quanto ao registo dos factores de risco cardiovascular. Os
indivíduos colaborantes foram questionados sobre o seu comportamento tabágico para avaliar
a concordância deste factor de risco com os registos. Os dados foram analisados
estatisticamente através do Software Package for Social Sciences 17.0® para Windows®. Foi
realizada uma análise bivariável através dos testes de McNemar e Chi-quadrado para
comparar variáveis categóricas.
Resultados: Foram analisados 289 processos dos quais 151 (52,2%) eram do sexo masculino e
138 (47,8%) eram do sexo feminino. A média de idades foi de 69,6 ± 15,93 anos. Os factores
de risco mais registados pelos médicos no internamento foram a hipertensão arterial (37,4%) e
a diabetes mellitus tipo 2 (22,1%). Verificou-se um maior registo de factores como a
hipertensão arterial e diabetes mellitus tipo 2 por parte dos médicos, e do álcool e
sedentarismo por parte dos enfermeiros, sendo estas diferenças estatisticamente
significativas (p=0,001).Dos 151 indivíduos colaborantes, 13,9% afirmou ser fumador mas
apenas 2% teve este comportamento tabágico registado no seu processo clínico. A idade <55
anos influencia o registo de factores como o tabagismo e o álcool (p=0,001). O registo do
tabagismo foi de 6,9% para as especialidades médicas, 7,3% para as cirúrgicas e 0% na
psiquiatria, a especialidade com maior prevalência de fumadores (62,5%).
Conclusão: O registo clínico electrónico é importante na medida em que permite uma melhor
abordagem individual na promoção da saúde. Neste centro hospitalar verificou-se que o
registo clínico da presença/ausência dos factores de risco cardiovascular pelos médicos e
enfermeiros no internamento foi muito inferior ao desejável.
Background: The clinical record of every medical event, morbidities e co morbidities in the internment allows a better prevention and treatment of chronic diseases. The presence of valid information in medical and nursing clinical records about cardiovascular and chronic disease risk factors is very important because it allows the reduction of the socioeconomic impact costs. The main objective of this investigation is to evaluate clinical practice as regards the record of smoking and other cardiovascular risk factors by physicians and nurses during the internment in Centro Hospitalar Cova da Beira. Methods: Cross sectional observational study. It was analyzed the clinical process of every hospitalized individuals regarding the record of cardiovascular risk factors. The cooperating individuals where questioned about their smoking behavior in order to evaluate the concordance of this risk factor with the records. Data were statistically analyzed by Software Package for Social Sciences 17.0® for Windows® . Bivariable analysis where conducted using chi-square and McNemar testes to compare categorical variables. Results: A total of 289 clinical processes were analyzed. 151 (52,2%) were mal and 138 (47,8%) were female. Mean age was 69,6 ± 15,93 years. HTA (37,4%) and DM 2 (22,1%) were the most recorded risk factors by physicians. Differences in the record of HTA, DM 2, alcohol and inactivity between physicians and nurses were statistically significant (p=0,001). Age <55 years affects the record of smoking and alcohol ingestion (p=0,001). Of the 151 individuals cooperating, 13.9% reported being a smoker but only 2% had this smoking behavior recorded in their medical file. Smoking records were 6,9% for medical specialties, 7,3% for surgical specialties and 0% in psychiatry, where the was the highest smoking prevalence (62,5%). Conclusions: The medical clinical record allows a better individual approach in the promotion of health. In this hospital, the medical and nursing clinical records of cardiovascular risks were by far inferior than the expected.
Background: The clinical record of every medical event, morbidities e co morbidities in the internment allows a better prevention and treatment of chronic diseases. The presence of valid information in medical and nursing clinical records about cardiovascular and chronic disease risk factors is very important because it allows the reduction of the socioeconomic impact costs. The main objective of this investigation is to evaluate clinical practice as regards the record of smoking and other cardiovascular risk factors by physicians and nurses during the internment in Centro Hospitalar Cova da Beira. Methods: Cross sectional observational study. It was analyzed the clinical process of every hospitalized individuals regarding the record of cardiovascular risk factors. The cooperating individuals where questioned about their smoking behavior in order to evaluate the concordance of this risk factor with the records. Data were statistically analyzed by Software Package for Social Sciences 17.0® for Windows® . Bivariable analysis where conducted using chi-square and McNemar testes to compare categorical variables. Results: A total of 289 clinical processes were analyzed. 151 (52,2%) were mal and 138 (47,8%) were female. Mean age was 69,6 ± 15,93 years. HTA (37,4%) and DM 2 (22,1%) were the most recorded risk factors by physicians. Differences in the record of HTA, DM 2, alcohol and inactivity between physicians and nurses were statistically significant (p=0,001). Age <55 years affects the record of smoking and alcohol ingestion (p=0,001). Of the 151 individuals cooperating, 13.9% reported being a smoker but only 2% had this smoking behavior recorded in their medical file. Smoking records were 6,9% for medical specialties, 7,3% for surgical specialties and 0% in psychiatry, where the was the highest smoking prevalence (62,5%). Conclusions: The medical clinical record allows a better individual approach in the promotion of health. In this hospital, the medical and nursing clinical records of cardiovascular risks were by far inferior than the expected.
Description
Keywords
Doenças cardiovasculares - Factores de risco Doença crónica - Factores de risco Doença crónica - Tabagismo Doença crónica - Registo clínico electrónico - Avaliação Internamento hospitalar - Prática clínica
Pedagogical Context
Citation
Publisher
Universidade da Beira Interior