Completeness of the Hospital Cancer Registry at a hospital in Florianópolis
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Abstract
Introduction: The Hospital Cancer Registry (HCR) is a systematic source of information aimed to improve the service provided to all cancer patients. Its database is essential for all professionals who attend to patients with cancer as it provides statistical data that allows to determinate the profile of patients, and so to direct the therapy to be adopted. Objective: To evaluate the completeness of the clinical and surgical oncology medical records of Maternity Carmela Dutra in 2009 and 2010, based on the variables of the HCR. Methods: A descriptive exploratory study was conducted with a secondary database provided by HCR. Cutoff points with different degrees were used for analysis of incompleteness of information from medical records. Results: Of the 405 records analyzed, 8.9% were in the poor category, 22.7% were classified in the fair category, 32.6% in the good and 35.8% in the excellent category. Family history of cancer and alcohol consumption remained largely the missing cases in the medical records. Conclusion: This study highlights the importance and need for improvement of medical records, with the structuring of required fields and standardization of medical records system.
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World Health Organization (WHO). World Cancer Report. World Health Organization; 2015. Disponível em: http://www.who.int/mediacentre/factsheets/fs291/en/. Acesso em: 20 dez. 2015.
Instituto Nacional do Câncer (INCA). Estimativa 2014: Incidência de Câncer no Brasil. Rio de Janeiro: INCA; 2014.
Instituto Nacioanl do Câncer (INCA). Estimativas 2016: incidência de câncer no Brasil. 2015. Disponível em: http://www.inca.gov.br/wcm/dncc/2015/index.asp. Acesso em: 20 dez. 2015.
Facina T. Estimativa 2014 – Incidência de Câncer no Brasil. Rev Bras Cancerol. 2014;60(1):63.
Ryan M, Stainton MC, Slaytor EK, Jaconelli C, Watts S, Mackenzie P. Aetiology and prevalence of lower limb lymphoedema following treatment for gynaecological cancer. Aust N Z J Obstet Gynaecol. 2003;43(2):148-51.
Ohsumi S, Shimozuma K, Kuroi K, Ono M, Imai H. Quality of life of breast cancer patients and types of surgery for breast cancer current status and unresolved issues. Breast Cancer. 2007;14(1):66-73. http://dx.doi.org/10.2325/jbcs.14.66
Rodrigues JSM, Ferreira NMLA. Caracterização do Perfil Epidemiológico do Câncer em uma Cidade do Interior Paulista: Conhecer para Intervir. Rev Bras Cancerol. 2010;56(4):431-41.
Romero DE, Cunha CB. Quality of socioeconomic and demographic data in relation to infant mortality in the Brazilian Mortality Information System (1996/2001). Cad Saúde Pública. 2006;22(3):673-84. http://dx.doi.org/10.1590/S0102-311X2006000300022
Silva PA, Riul SS. Câncer de mama: fatores de risco e detecção precoce. Rev Bras Enferm. 2011;64(6):1016-21. http://dx.doi.org/10.1590/S0034-71672011000600005
O’Brien B, Koru-Sengul T, Miao F, Saclarides C, Tannenbaum SL, Alghamdi H, et al. Disparities in Overall Survival for Male Breast Cancer Patients in the State of Florida (1996-2007). Clin Breast Cancer. 2015;15(4):e177-87. http://dx.doi.org/10.1016/j.clbc.2014.12.010
Pinto IV, Ramos DN, da Costa MCE, Ferreira CBT, Rebelo MS. Completude e consistência dos dados dos registros hospitalares de câncer no Brasil. Cad Saúde Coletiva. 2012;20(1):113-20.
Caligtan CA, Dykes PC. Electronic health records and personal health records. Semin Oncol Nurs. 2011;27(3):218-28. http://dx.doi.org/10.1016/j.soncn.2011.04.007
Veras CM, Martins MS. Reliability of data from Authorization Forms for Hospital Admittance, Rio de Janeiro, Brazil. Cad Saúde Pública. 1994;10(3):339-55. http://dx.doi.org/10.1590/S0102-311X1994000300014
Glatt R. Análise da qualidade da base de dados de AIDS do Sistema de informação de agravos de notificações (SINAN). Tese (Mestrado) - Escola Nacional de Saúde Pública Sérgio Arouca. Rio de Janeiro: Fundação Oswaldo Cruz; 2005.
Oliveira MEP, Soares MRAL, Costa MCN, Mota ELA. Avaliação da completude dos registros de gebre tifóide notificados no Sinan pela Bahia. Epidemiol Serv Saúde. 2009;18(3):219-26.
Souza RC, Freire SM, Almeida RT. An information system to integrate outpatient cancer care data in the Unified National Health System. Cad Saúde Pública. 2010;26(6):1131-40. http://dx.doi.org/10.1590/S0102-311X2010000600007
Brasil. Ministério da Saúde. Controle do câncer de mama: documento de consenso. Rev Bras Cancerol. 2004;50(2):77-90.
Instituto Nacional do Câncer (INCA). A situação do câncer no Brasil. 2006. Disponível em: http://www1.inca.gov.br/enfermagem/docs/cap1.pdf. Acesso em: 19 jan. 2016.
Nguyen L, Bellucci E, Nguyen LT. Electronic health records implementation: an evaluation of information system impact and contingency factors. Int J Med Inform. 2014;83(11):779-96. http://dx.doi.org/10.1016/j.ijmedinf.2014.06.011
Correia LO, Padilha BM, Vasconcelos SM. Methods for assessing the completeness of data in health information systems in Brazil: a systematic review. Cienc Saúde Colet. 2014;19(11):4467-78. http://dx.doi.org/10.1590/1413-812320141911.02822013
D’Alessandro TAL, Antoniazze BN, Abreu DMX. Hospitalbased cancer registries of Minas Gerais, Brazil: analysis of the consistency of databases. Cad Saúde Colet. 2010;18(3):410-7.
Jorge MHPM, Laurenti R, Gotlieb SLD. Avaliação dos sistemas de informação em saúde do Brasil. Cad Saúde Coletiva. 2010;18(1):7-18.
Lima CR, Schramm JM, Coeli CM, Silva ME. Review of data quality dimensions and applied methods in the evaluation of health information systems. Cad Saúde Pública. 2009;25(10):2095-109. http://dx.doi.org/10.1590/S0102-311X2009001000002
Informes Técnicos Institucionais. Information integration of Brazilian cancer registries. Rev Saúde Pública. 2007;41(5):865-8. http://dx.doi.org/10.1590/S0034-89102007000500024
Silva GF, Aidar T, de Freitas Mathias TA. Quality of the Live Birth Information System in the state of Parana, from 2000 to 2005. Rev Esc Enferm USP. 2011;45(1):79-86. http://dx.doi.org/10.1590/S0080-62342011000100011
Corradi-Webster CM, Laprega MR, Furtado EF. Residentes em psiquiatria têm documentado problemas relacionados ao álcool em pacientes ambulatoriais? Rev Psiquiatr Rio Gd Sul. 009;31(3):187‑91. http://dx.doi.org/10.1590/S0101-81082009000300008
Fernandes GL, Santos RE, Malafaia O, Aoki T. Development of an electronic protocol for uterine cervical cancer. Rev Col Bras Cir. 2012;39(1):28-32. http://dx.doi.org/10.1590/S0100-69912012000100007
Andrade CT, Magedanz AM, Escobosa DM, Tomaz WM, Santinho CS, Lopes TO, et al. The importance of a database in the management of healthcare services. Einstein. 2012;10(3):360-5. http://dx.doi.org/10.1590/S1679-45082012000300018
Oselka G. Prontuário Médico. Rev Assoc Med Bras. 2002;48(4):275‑96.
Vasconcellos MM, Gribel EB, Moraes IH. Health records: evaluation of patient health charts in primary care, Rio de Janeiro, Brazil. Cad Saúde Pública. 2008;24(Suppl. 1):S173-82. http://dx.doi.org/10.1590/S0102-311X2008001300021
Burke HB, Sessums LL, Hoang A, Becher DA, Fontelo P, Liu F, et al. Electronic health records improve clinical note quality. J Am Med Inform Assoc. 2015;22(1):199-205. http://dx.doi.org/10.1136/amiajnl-2014-002726
Pego-Fernandes PM, Werebe E. Electronic medical files for patients: some steps towards the future. São Paulo Med J. 2010;128(6):317-9. http://dx.doi.org/10.1590/S1516-31802010000600001