RESUMO
Introducción. Analizar en las historias clínicas de un centro de salud la existencia o no de datos acerca del proceso de información sobre los efectos secundarios e interacciones de los analgésicos y antiinflamatorios en una población, y establecer asimismo el perfil de los pacientes respecto a la existencia o no de información a este respecto en su historia clínica. La historia clínica no es solo un documento que nos exige la ley, sino que es o debe ser una herramienta asistencial de primer orden, que facilita y ayuda en el proceso asistencial. La cumplimentación adecuada de las historias clínicas es una obligación del profesional además de ser nuestra herramienta de trabajo, pero en la historia clínica de atención primaria no siempre se registra la información generada durante la práctica asistencial. Material y métodos. Estudio descriptivo, transversal. Se revisaron las historias clínicas de 232 pacientes pertenecientes a los 8 cupos informatizados del centro de salud, mayores de 18 años y que dieron su consentimiento verbal para la inclusión en el estudio, pertenecientes al Centro de Salud Mariano Yago de Yecla (ÁreaV, comunidad de Murcia). Resultados. El 21,6% de los facultativos anota en la historia que proporciona información sobre los efectos secundarios e incompatibilidades de la prescripción de analgésicos y antiinflamatorios. Los factores que se relacionan con la ausencia de haber proporcionado información en la historia clínica son: el tipo de prescripción, el tipo de analgésico y antiinflamatorio prescritos, las variables sobre la función renal y el cumplimiento de la gastroprotección. Conclusiones. En las historias clínicas faltan registros sobre la información que se proporciona al paciente consumidor de analgésicos y antiinflamatorios (AU)
Introduction. To examine medical records within a health centre to determine whether there are data in the information process on the secondary effects and interactions of analgesic and anti-inflammatory drugs, and to determine the patient profile as regards whether or not this information is recorded in their medical records. Material and methods. Descriptive, cross-sectional study based on electronic medical records in the Mariano Yago Primary Care Centre in Yecla (Murcia), Spain. A systematic random sample of 232 electronic medical records was reviewed. All the 232 patients, of legal age, gave their consent to review of their electronic medical records for the purposes of the study. Results. The percentage of doctors who recorded the fact that they had provided information regarding secondary effects and non-compatibilities of the prescription of analgesic and anti-inflammatory drugs was 21.6%. The factors involved in the non- recording of this information in the medical record were the type of prescription, the type of analgesic and anti-inflammatory drug prescribed, glomerular filtration, and adequate gastrointestinal protection. Conclusions. The degree of compliance to patients rights to information about treatment with analgesic and anti-inflammatory drugs is low (AU)
Assuntos
Humanos , Masculino , Feminino , Adulto , Pessoa de Meia-Idade , Idoso , Idoso de 80 Anos ou mais , Anti-Inflamatórios/uso terapêutico , Analgésicos/uso terapêutico , Prontuários Médicos/estatística & dados numéricos , Prontuários Médicos/normas , Controle de Formulários e Registros/organização & administração , Controle de Formulários e Registros/normas , Atenção Primária à Saúde/métodos , Atenção Primária à Saúde/tendências , Atenção Primária à Saúde , 51835/métodos , Controle de Formulários e Registros/métodos , Controle de Formulários e Registros/tendências , Controle de Formulários e Registros , Atenção Primária à Saúde/organização & administração , Atenção Primária à Saúde/normas , Estudos Transversais/métodos , Estudos Transversais , Intervalos de ConfiançaRESUMO
INTRODUCTION: To examine medical records within a health centre to determine whether there are data in the information process on the secondary effects and interactions of analgesic and anti-inflammatory drugs, and to determine the patient profile as regards whether or not this information is recorded in their medical records. MATERIAL AND METHODS: Descriptive, cross-sectional study based on electronic medical records in the Mariano Yago Primary Care Centre in Yecla (Murcia), Spain. A systematic random sample of 232 electronic medical records was reviewed. All the 232 patients, of legal age, gave their consent to review of their electronic medical records for the purposes of the study. RESULTS: The percentage of doctors who recorded the fact that they had provided information regarding secondary effects and non-compatibilities of the prescription of analgesic and antiinflammatory drugs was 21.6%. The factors involved in the non- recording of this information in the medical record were the type of prescription, the type of analgesic and anti-inflammatory drug prescribed, glomerular filtration, and adequate gastrointestinal protection. CONCLUSIONS: The degree of compliance to patients rights to information about treatment with analgesic and anti-inflammatory drugs is low.
