Patient´s record as a subsidy professional´s practice in the shared clinical

DOI: 10.15343/0104-7809.20164002151159

Abstract

The shared clinic presupposes an active and autonomous professional behavior of the health team has the patient as the
center of health care. This can contribute to the improvement in health services, for example, reducing the stay hospital,
which can positively influence patient care and hospital management. This study aimed to analyze the health care
needs, as support for shared clinical management, by hospitalization´s care at the admission and discharge, through
information available in medical records, that they can discussed as a resource for professional practice guided by shared
clinic. The health care needs related to hospital admission and discharge care needs reported in the patient´s medical
records. The study was correlational, cross-sectional and quantitative. There were analyzed 430 medical records of two
public hospitals in São Paulo. The study demonstrated that an increased number of care needs at patient admission
and discharge related to increased length of stay, numbers of diagnoses and age. Furthermore, some medical records
presented a high number of care needs at discharge, even though they reduced compared to admission. Within the
perspective of shared clinical, we can conclude that the activity of monitoring the numbers of care needs, as well as
other health care indicators, may contribute to the work of multidisciplinary health care teams and to the hospital
management.