As questões que cercam o prontuário: um estudo sobre as demandas recebidas pelo conselho regional de medicina do Estado do Ceará

Abstract

The present study seeks to understand what are the main questions about issues related to patient records, addressed to the Regional Council of Medicine of the State of Ceará (CREMEC), both by the community that deals with this document and by ordinary citizens. The main objective of this research is to analyze the types of demands that reach CREMEC forwarded by the community that deals with patient records, whether analog or digital, as well as those coming from ordinary citizens regarding this document. As for the methodology, it is based on an exploratory, bibliographic and documental research, with a quanti-qualitative approach. Regarding the documental research referring to the archival documentation, the empirical research was done in the CREMEC protocol system in its physical archive, analyzing the demands that came to the "Processo-Consulta" sector and were answered through opinions and/or Direct Answers. The time interval of the study coverage was 23 years, that is, the period between 1999 and 2022. The results show that the most frequently asked questions about the patient's medical record are divided, in order of frequency, into: access/release, custody, structure and electronic record, subjects of extreme importance for the doctor's daily professional life. We conclude that the most frequently asked questions about the mapped subjects show the importance that each theme has for the use of the medical record, a document that is linked to the life of a person, the professional secrecy of the physician, administrative, legal, economic, social, historical, and research factors. Finally, we highlight the relevance of CREMEC and the Consultation-Process sector, in clarifying the issues that surround health professionals and the community regarding the theme of the medical record.