O prontuário do paciente de Serviço de Oncologia da Santa Casa de Misericordia de Belo Horizonte: fonte de informação para melhor atenção no tratamento do pacientecom câncer

Abstract

Accesses the medical records of the Oncology Department from Santa Casa Hospital of Belo Horizonte using the perspective of cancer information source, its presents the medical records characteristics like: confidentiality, access, guardianship and historical facts. The aim of the study was to analyze the patient's medical records as a source of cancer information. The study was conducted from May to October 2012and to write the literature reviews, was used documentary analysis, research in the hospitals historical records. In the literature review were addressed topics like: health information source, the electronic medical record, the Cancer Registry and medical records rules and laws. The results indicate that medical records were created to register the patient's clinical history in the Hospital and the changes were an improvement in detail of the patient and the addition of new tests as cancer treatmenthas evolved. Many details were added due to RHC. The changes perceived in the medical records were improved as the treatment of cancer has development. Many information details were added on the records to support the Cancer Registry. We concluded that the use of the records goes further the patient care and administrative activities, which is used for epidemiological studies, clinical research, academic andscientific papers, as a source of diagnosis, disease progression and treatments and as a source of oncology information for cancer estimates of new cases of cancer from Brazil's National Cancer Institute