Patient identification in the records of health professionals

Abstract

Objective: Identify the conformity of patient identification data in the records of health professionals from three public hospitals in Rio Grande do Norte. Methods: A cross-sectional study was carried out at the medical and surgical clinical nursing wards of three public hospitals in Rio Grande do Norte, Brazil. The sample consisted of patients hospitalized in these wards for at least ten days, between October and November 2016. The data were analyzed descriptively, using absolute frequencies and the Pareto Diagram. Results: Non-conformity was found in the header data birth date and affiliation, which was responsible for 61% of inadequacies in the medical evolutions, 65% in the nursing team notes and 62% in the opinions of doctors and the other categories. Conclusion: The study revealed that the headers of the health professionals' records in the hospitals analyzed do not guarantee correct patient identification and patient safety.