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Previous issue date: 2017-08-31 === A comunica??o escrita ? uma ferramenta que contribui com a redu??o de danos ao paciente, uma vez que possibilita a unifica??o dos registros da equipe multidisciplinar e a continuidade da assist?ncia. Diante disso, este estudo objetiva analisar a comunica??o escrita dos profissionais de sa?de em hospitais p?blicos do estado do Rio Grande do Norte, Brasil. Trata de um estudo transversal que se baseia nas recomenda??es da Organiza??o Mundial de Sa?de, quanto a constru??o ?Record review of current in-patients?. Seguiram-se as etapas: 1) constru??o da Scoping review; 2) sele??o e treinamento dos examinadores de registros; 3) testagem dos procedimentos de avalia??o do registro (estudo piloto); e 4) desenvolvimento da revis?o de registros. A coleta de dados nos prontu?rios ocorreu no per?odo de outubro a dezembro de 2016, em tr?s hospitais p?blicos de Natal, nos setores de enfermarias de cl?nica m?dica e cir?rgica. Foram inclu?dos na amostra os pacientes internados h? pelo menos 10 dias. Os dados foram organizados por meio de um pacote estat?stico e analisados de forma descritiva, por meio de frequ?ncia absoluta e relativa e Diagrama de Pareto. O estudo segue os preceitos ?ticos estabelecidos pela Resolu??o n? 466/2012, do Conselho Nacional de Sa?de. Os resultados destacaram que o conte?do da comunica??o escrita compreende os elementos comuns aos registros ? identifica??o do paciente e profissional, letras leg?veis, uso de siglas e abreviaturas padronizadas, aus?ncia de rasura e in?cio dos escritos com data e hora ? e elementos espec?ficos a cada categoria profissional. A partir da revis?o de prontu?rios evidenciou-se os principais dados em n?o conformidades: 1) identifica??o do paciente (cabe?alhos) - data de nascimento e filia??o na identifica??o do paciente; 2) evolu??es m?dicas - aspectos do exame f?sico, antecedentes pessoais e familiares, h?bitos e condi??es de moradia do paciente, intercorr?ncias, resultados laboratoriais e de imagem nas evolu??es m?dicas; 3) anota??es do t?cnico de enfermagem - h?bitos de vida, presen?a de alergia, identifica??o do acompanhante, uso de medicamento quanto ao tipo, condi??es gerais acerca da atitude, humor, locomo??o e colora??o da pele, estado nutricional e orienta??es ao paciente/acompanhante nas anota??es do t?cnico de enfermagem; 4) controles essenciais ? unidade de medida ap?s o sinal vital; 5) anota??es do enfermeiro - identifica??o do acompanhante, colora??o da pele, elimina??es quanto ? consist?ncia, odor e colora??o; orienta??o do paciente/acompanhante; aspectos sobre exame f?sico, h?bitos de vida e presen?a de alergias; 6) elementos comuns da comunica??o escrita ? letras leg?veis, in?cio dos registros com hora e uso de abreviaturas; e 7) identifica??o profissional ? categoria e n?mero no conselho de classe. Conclui-se que a comunica??o escrita dos profissionais de sa?de, nos tr?s hospitais analisados, apresenta n?o conformidades nos dados de identifica??o do paciente e profissional, nos registros admissional e di?rio tanto de m?dicos e como da equipe de enfermagem. Assim, a??es para a melhoria da comunica??o escrita dos profissionais nos hospitais analisados, como tamb?m contribuir com as discuss?es acerca dessa tem?tica s?o recomendadas para se efetivar a comunica??o e o cuidado seguro. === Written communication is a tool that contributes to reducing patient harm, since it allows the unification of multidisciplinary team records and continuity of care. As such, this study aims to analyze the written communication of health care professionals in public hospitals in Rio Grande do Norte state, Brazil. This is a cross-sectional study based on the recommendations of the World Health Organization regarding the construction of a ?Record review of current in-patients?. It included the following stages: 1) performing a scoping review; 2) selecting and training record examiners; 3) testing record assessment procedures (pilot study); and 4) conducting the record review. Data were collected from medical records in the wards of the medical and surgical clinics in three public hospitals in the city of Natal, between October and December 2016. Patients hospitalized for at least 10 days were included in the sample. The data were organized in a statistical package and analyzed descriptively by absolute and relative frequency and a Pareto chart. The study complied with the ethical principles established by Resolution 466/2012 of the Brazilian National Health Council. The results highlight that written communication includes common elements ? information on the patient and medical professional, legible writing, the use of standardized acronyms and abbreviations, lack of erasures, and records initiated with the date and time ? and aspects that are specific to each professional category. The main nonconformities identified in the record review were: 1) patient identification (headers) ? date of birth and parents? names in the patient information; 2) progress notes ? aspects of the physical examination, personal and family history, patient?s habits and living conditions, complications, lab and imaging results; 3) notes by the nursing technician ? lifestyle habits, allergies, companion?s identification information, type of medication used, general health status in terms of behavior, mood, movement ability and skin color, nutritional status and guidance for the patient/companion; 4) essential controls ? unit of measurement after vital signs; 5) nurse?s notes - companion?s identification information, skin color, consistency, color and odor of urine/stools, guidance for the patient/companion, aspects of the physical examination, lifestyle habits and allergies; 6) common elements of written communication ? legible writing, records initiated with the date and time, use of abbreviations; and 7) medical professional?s information ? medical specialty and registration number. It was concluded that the written communication of health care professionals in the three hospitals studied exhibits nonconformities in the identification information of patients and professionals in both the admissions and daily records of doctors and nurses. Thus, action is recommended to improve the written communication of staff in the hospitals analyzed and contribute to discussions on the theme, in order to ensure effective communication and safe care.
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