Representação Temática da Informação no Prontuário do Paciente: um estudo sobre o uso da CID-10 nas Organizações de Saúde localizadas em Fortaleza-CE

Abstract

Introduction: thematic representation of information consists of extracting the main subjects from the documents in order to enable the organization to access and informationretrieval. It can be done by adopting a natural language (LN) or documentary language (LD). In the area of Health, we find numerous documentary languages, particularly the International Statistical Classification of Diseases and Related Health Problems, known as ICD-10, in portuguese. This language is adopted by health organizations to code / index patient records, with codes referring to the disease(s) the subject is being treated. Objective: the objective is to investigate the way in which the patient records are codified in health organizations in Fortaleza. Method: it is an exploratory research with a qualitative approach, whose empirical study was carried out with a group of nine professionals who work in health organizations. The data were collected through structured interview, applied directly by the researchers in the selected places. Results: the results highlights that ICD-10 is used due to its mandatory, however, there are no rules regarding coding practice. Conclusion: We also conclude that it is not being used in the perspective of representation, organization, access and information retrieval in the researched institutions and that there is a lack of knowledge about this activity by the interviewees