Terapia ocupacional, registro em prontuário e as percepções da equipe hospitalar

Abstract

Among the procedures carried out by the occupational therapist in the hospital is the medical record. The record in the medical record aims to facilitate communication among professionals, support decision making, promote the quality of comprehensive care, guide the establishment of the patient's needs and potential as a single subject and integrate the various knowledge. Aiming at understanding the use of medical records by the hospital team and the access to the records produced by occupational therapists, this exploratory study, with a qualitative approach, interviewed professionals from the multidisciplinary team working in a medical clinic ward, using the snowball method for participant selection. The interviews were conducted through the Google Meet platform, and the information was transcribed and analyzed by thematic content. The information about the purpose of this use was organized into three categories: documentation of care practice, consultation of data about the patient and about his care plan and communication/exchange of information between team members. It was evaluated that the records produced by occupational therapists help other professionals in care planning, and the consultation of these records is based on two categories: verification of interventional information for alignment of the care plan, understanding of the impacts of illness and adaptive responses. The content of such categories show the search for information beyond functional and rehabilitation aspects, as well as the impacts experienced by the patient with the process of illness and hospitalization, a factor that highlights an expanded and contemporary look about the scope of occupational therapy. It was concluded that the structuring of information was pointed out as a potentiality of occupational therapeutic records, however, there was perceptive variability about the level of clarity of information, a factor associated with professional training and the substantiation of information from the occupational perspective.