Avaliação das informações contidas nos encaminhamentos dos pacientes da atenção primária do município de Rio do Sul (SC)

Eloyve Joaquim  Ramos Junior; Franciani Rodrigues da Rocha

doi:10.5712/rbmfc18(45)3358

Authors

Eloyve Joaquim Ramos Junior Centro Universitário para o Desenvolvimento do Alto Vale do Itajaí – Rio do Sul (SC), Brasil. https://orcid.org/0000-0002-3259-8532
Franciani Rodrigues da Rocha Centro Universitário para o Desenvolvimento do Alto Vale do Itajaí – Rio do Sul (SC), Brasil. https://orcid.org/0000-0002-0409-2163

DOI:

https://doi.org/10.5712/rbmfc18(45)3358

Keywords:

Primary Health Care, Referral and Consultation, Health information exchange.

Abstract

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.

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Author Biography

Franciani Rodrigues da Rocha, Centro Universitário para o Desenvolvimento do Alto Vale do Itajaí – Rio do Sul (SC), Brasil.

Graduada em fisioterapia pela Universidade do Extremo Sul Catarinense (UNESC), pós-graduada em Atenção Básica/Saúde da Família pelo Ministério da Saúde/UNESC, pós-graduada em Gestão da Atenção Básica em Saúde pelo Ministério da Saúde/UNESC, Mestre em Ciências da Saúde pela UNESC e doutora em Ciências da Saúde pela UNESC. Atualmente é docente dos cursos de Educação Física, Fisioterapia, Medicina e Nutrição da UNIDAVI. Membro do núcleo docente estruturante (NDE) do Curso de Fisioterapia e Nutrição da UNIDAVI. Assessora em Análise Estatística e docente de cursos de curta duração presenciais e on-line.

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