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M. Cooper
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摘要

本研究的目的是评估过去五年来巴西南部一所毕业机构综合儿童医院的本科生完成医疗记录的情况,以及他们获得的x线片的质量。在大学研究伦理委员会批准后,数据由先前校准的本科生在儿童诊所收集,通过长达12年的患者记录,总计378份医疗记录和354张x光片样本。收集的数据包括患者身份、文件、临床数据、程序和构成牙科记录的其他信息,以及涉及处理、技术和x光片存储的x光片错误。可以核实的是,学生填写的记录中有50%完成了牙科检查,但没有法律责任人的签名;大约53%的人没有计划甚至没有完成牙齿检查;年龄和牙床肤色无显著性差异。在评估的x线片中,66%是7岁以上的儿童,50%是男性,68.5%是根尖周围技术。从观察结果来看,“存储错误”是最常见的,其次是“数字错误”。x线摄影时的误差在1.1 - 22%之间。结果表明,该本科生的病案填写质量不理想,x线片及其存储质量也不理想。
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No
The objective of this present study was to evaluate the completion of medical records by undergraduate students at the Integrated Children's of a South Brazilian Graduation Institution over the past five years, as well as the quality of the radiographs obtained by them. After the University Research Ethics Committee approval, the data were collected by previously calibrated undergraduate students, at Children’s Clinic through patients records up to 12 years, totaling a sample of 378 medical records and 354 radiographs. The collected data include patient identification, documentation, clinical data, procedures and other information that make up the dental record, as well as radiographic errors involving processing, technique and radiographs storage. It was possible to verify that 50% of the records filled out by the students have the completion of the dental chart, but there was no signature of the legal responsible; that approximately 53% did not have a planning or even an odontogram completed; There was no significance regarding to age and odontogram complexion. Among the radiographs evaluated, 66% were children over 7 years old, 50% male, 68.5% performed by the periapical technique. From the observed the “incorrect storage” was the most present, followed by the “presence of digital” error. Errors during radiographic taking ranged from 1.1 to 22%. It was concluded that the quality of the medical records filling made by the undergraduate students is unsatisfactory, as well as the quality of the radiographs and their storage.
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