Análise da completude de prontuários de mulheres com sífilis gestacional

Abstract

Introduction: During prenatal care, it is part of the nurse's job to pass on information about the perinatal complications and their notes should be recorded with quality. Surgent the objective of evaluating the level of effectiveness of the conduct and treatment for syphilis in pregnant women from the completeness of the information stored in medical records. Methodology: This is a retrospective, descriptive, explanatory study of a quantitative approach, which seeks to evaluate the completeness of information on cases of gestational syphilis from their respective medical records stored in basic health units in the city of Macapá. Results and Discussion: The analysis is available from the total of 21 medical records found. The degree of completeness was established from the exclusion of unfilled and/or blank fields. From the data analysis, it was observed that none of the variable axes reached a "good" or "excellent" degree of completeness. In 2019, a very poor filling (14.29%) of the race/color of pregnant women was observed. In 2020 the filling was completely ignored (100%). Final considerations: It was evidenced that there is no completeness of information recorded in the medical records of women with gestational syphilis in the municipality studied. Inadequate forms of filling, weaknesses in the storage of data and deficiencies of stored information were found, generating risks for the pregnant woman and her baby.