The registration teaching of medical records in the hospital occupational therapy context¹

Abstract

Considering the obligation of registration of the medical records whenever there are consultations provided by the occupational therapist, as well as notes on the need for greater investments in initial and continuing education about this theme, this study sought to stratify data about the teaching process in the Brazilian graduation about the medical record in the field of occupational therapy in hospital contexts. This is a documentary study, being initially carried out a consultation in the E-mec system to verify the active courses of occupational therapy in Brazil. This survey consisted of the e-mailing of a questionnaire to the courses coordinations to map the theoretical subjects and occupational therapy internships in hospital settings and, consequently, the capture of the respective syllabus, which were analyzed through descriptive statistics. The final sample involved 24 questionnaires filled out by the course coordinators and 28 syllabi, being found in only 11 of them, the content linked to the research topic. It was verified that the teaching of medical record occurs especially harnessed to the practice and based on the scanty presentation of theoretical fundamentals as norms and models. The weaknesses observed imply in the tensions about the professional public discourse since the annotations in medical records constitute a way of recognition of the occupational therapeutic work and foundation of scientific researches.

Keywords:
Teaching; Occupational Therapy; Records as Topic

Resumo

Considerando a obrigatoriedade do registro em prontuário sempre que houver atendimentos efetivados pelo terapeuta ocupacional, bem como apontamentos sobre a necessidade de maiores investimentos na educação inicial e continuada acerca desta temática, este estudo buscou estratificar dados acerca do processo de ensino na graduação brasileira sobre o registro em prontuário no campo da terapia ocupacional em contextos hospitalares. Trata-se de um estudo documental, sendo inicialmente realizado consulta no sistema E-mec para verificação dos cursos de terapia ocupacional ativos no Brasil. Este levantamento viabilizou o encaminhamento por e-mail de um questionário às coordenações dos cursos para mapeamento das disciplinas teóricas e de estágios profissionalizantes de terapia ocupacional em contextos hospitalares e em consequência, a captação das respectivas ementas, as quais foram analisadas por meio de estatística descritiva. A amostra final envolveu 24 questionários preenchidos pelos coordenadores de curso e 28 ementas, sendo constatado em apenas 11 das ementas conteúdos vinculados a temática pesquisada. Verificou-se que o ensino sobre o registro em prontuário ocorre especialmente atrelado à prática e pautado em escassa apresentação de fundamentos teóricos como normativas e modelos. As fragilidades constatadas implicam em tensionamentos acerca do discurso público profissional visto que as anotações em prontuário constituem-se como uma via do reconhecimento do trabalho terapêutico ocupacional e alicerce de pesquisas científicas.

Palavras-chave:
Ensino; Terapia Ocupacional; Registros como Assunto

1 Introduction

1.1 Teaching in occupational therapy and the hospital context

The World Federation of Occupational Therapists - WFOT shows minimum standards for the training of occupational therapists, which are established from four interrelated axes: social, professional, ethical and educational. These standards were established based on the main domains that distinguish occupational theray2ypy from other professions and reinforce the integrity of professional skills, abilities, and attitudes (WORLD..., 2016).

The teaching in occupational therapy in Brazil is guided by the National Curricular Guidelines (DCNs). In its article 3, it is mentioned that:

The Undergraduate Course in Occupational Therapy has an occupational therapist egress graduate/professional profile with a generalist, humanistic, critical and reflective background. He is qualified to the professional exercise in all its dimensions, based on ethical principles, in the clinical-therapeutic field and preventive of the practices of occupational therapy. It knows the historical, philosophical and methodological foundations of occupational therapy and its different models of intervention and acts based on scientific and intellectual rigor (BRASIL, 2002a, p. 1).

In the DCNs, there is a description of the general and specific skills and the ability for the training of the occupational therapist, and it is indicated in its article 5, the accomplishment of the internship in different social and health facilities such as the hospital (BRASIL, 2002a).

The hospital is an area of activity for the occupational therapist since the beginning of the profession. Practices in this area have undergone modifications over time through the need to adapt to the demands of modernity (DE CARLO; LUZO, 2004).

In a study developed by Dahdah, Frizzo and Fangel (2014), with the objective of characterizing the teaching in Brazilian undergraduate courses in occupational therapy in hospital contexts, the reduced supply of specific subjects and practices in the hospital were verified.

Considering a sample of 33 universities, only 14 courses (42.4%) offered subjects related to hospital contexts and only 12 courses (36, 4%) offered practical activities in the hospital. The authors, among some notes, express the need to reflect on how much the DCNs contemplate the evolution of the profession (DAHDAH; FRIZZO; FANGEL, 2014), considering Resolution 429/2013 of the Federal Council of Physiotherapy and Occupational Therapy - COFFITO which recognizes the specialty of occupational therapy in hospital settings (CONSELHO..., 2013).

1.2 Registration of medical records

According to Resolution 415/2012, article 1, the medical record is a mandatory procedure among the occupational therapist's duties (CONSELHO..., 2012).

As a minimum composition of the medical record needs to have information on patient identification (name, naturalness, marital status, religion, place, and date of birth, profession, business, and residential address), clinical history (complaints, history of the illness, personal and family history, treatments performed), description of occupational profile and quality of life, occupational diagnosis and prognosis, treatment plan, data about clinical evolution and identification of the professional (CONSELHO..., 2012).

The information registered should reflect the clinical reasoning and chronologically allow the visualization of the course of the therapeutic intervention and the occupational performance of the patient throughout the care process (AMERICAN..., 1995).

As principles of quality for documentary formulation, McGuire (1997) refers to the need for records in occupational therapy to include prioritization of functions and meanings of activities, progress reports in performance areas, explanation of clinical problems and function, as well as information about changes such as those of functional gains, disability reductions, factors linked to slow progress, among others.

The documentary quality has increasingly become the focus of attention of the hospital institutions, considering that through the medical record, there are the extracts data linked to productivity and billing, information that allows the visualization of the clinical evolution and quality of care (POSSARI, 2007). Such records support the health professional legally because it constitutes adequate proof of legal defense (CONSELHO..., 2012), thus the documentary quality has increasingly become the focus of attention of hospital institutions.

The hospital accreditation processes include data about the documentation in medical records in their evaluation, considering these annotations as one of the variables of patient care quality and safety (BRASIL, 2002b). Nonetheless, the National Humanization Policy (HNP) approaches transdisciplinary work among its premises, presenting the medical record as a tool that stimulates and strengthens teamwork and dialogue among professionals (BRASIL, 2004).

In Brazilian occupational therapy, small studies with documentary themes are found (PANZERI; PALHARES, 2013; BOMBARDA; PALHARES, 2015; PELISSARI; PALHARES, 2015). However, Panzeri (2013) expresses the need for greater investments in teaching about medical records in undergraduate and postgraduate courses and in continuing professional education.

Therefore, understanding that the registration in the medical records is relevant in the care, administrative and legal areas, this study sought to stratify data about the teaching process in the Brazilian undergraduate study on the medical record in the occupational therapy area in a hospital context.

2 Method

This is documentary research, with the research of contemporary and retrospective documents, with the quantitative and descriptive approach, carried out in the first semester of 2017.

For Gil (2002), documentary research is elaborated from materials that did not receive analytical treatment. It consists of the analysis of contemporary or retrospective documents, scientifically authentic, for the purpose of describing or comparing social facts (PÁDUA, 1997).

The quantitative approach is based on the organization of the data in tables by statistical treatment, a factor that facilitates the logical ordering of the work, allowing the description of the information (GIL, 2002).

This research was approved by the Human Research Ethics Committee of UFSCar (opinion 1,894,915), with CAAE nº 61770616.6.0000.5504, as recommended by the Research Standards Involving Human Beings (Resolution CNS 466/12) of the National Health Council.

To obtain the data, information from a questionnaire and the menus of theoretical and professional training in hospital contexts were established as a source of research.

For the design of the sample, a survey of the undergraduate courses in occupational therapy active in Brazil, both public and private, was carried out through the E-mec system of the Ministry of Education (BRASIL, 2018). After refinement of the data, a sample of forty institutions of higher education registered with offers of undergraduate courses were obtained.

The data collection occurred with the sending of electronic mail to the coordinators of the institutions of higher education, registered and active, from March to June 2017. The content of the electronic mail involved:

1. a

   presentation and purpose of the research, contact of the researcher responsible and copy of the favorable opinion of the ethics committee in human research at UFSCar;

2. b

   request to complete a questionnaire, composed of three questions: 1) Does the course offer the theoretical subject of occupational therapy in hospital settings?; 2) Does the course offer vocational training in occupational therapy in hospital settings?; 3) In the case of the offer of internships, do all or some of the students attend the vocational training course in occupational therapy in hospital settings?

3. c

   request to send the documents in case of an offer of theoretical and/or professional training in occupational therapy in a hospital context.

Only for those answers in which there was the signaling of the offer of courses for the course, but lacking the referral of their respective menus, a survey was made on the institutional sites of higher education.

From the material obtained, an analysis was performed using descriptive statistics, which consists of a summary of the main characteristics of a dataset with tables, graphs and numerical indices (GUIMARÃES, 2008).

3 Results

From a sample of 40 registered and active higher education institutions, represented by their respective course coordinators, only 24 (60%) institutions answered, so they were the participants of this study.

A total of 56 sources, consisting of 24 questionnaires and 32 hospital context menus (16 of the theoretical subjects and 16 referring to professional training) were added. However, four vocational training sessions were excluded, since two sets were configured as theoretical subject practices and the others for not having as a primary focus the practical teaching of the performance of occupational therapy in hospital contexts.

Thus, the final sample consisted of 52 sources, of which 24 questionnaires were filled out by the course coordinators and 28 menus (16 of theoretical subjects and 12 of vocational courses), according to Figure 1.

Figure 1
Synthesis of the data collection of the documentary step.

In 24 respondents, 45.9% of them are represented by federal institutions, followed by 41.6% of private institutions, with most of the participating courses (54.2%) located in the southeast region, according to data explained in Table 1.

Table 1
General characterization of the sample.

Undergraduate course in OT	N (24)	%
Institutional nature	Federal 11	45.9
	State 3	12.5
	Private 10	41.6
Institutional Location	North 2	8.3
	Northeast 1	4.2
	Central-West 1	4.2
	Southeast 13	54.2
	South 7	29.1
Theoretical subjects offer of OT in hospital contexts	Yes 13	54.2
	No 11	45.8
Professional internship offer of OT in hospital contexts	Yes 17	70.8
	No 7	29.2
Amount of students who attend the professional internship of OT in hospital contexts	Some of the students 9	53
	All the students 8	47
Theoretical teaching time of OT in hospital contexts*	30 to 50 hs 7	43.7
	51 to 75hs 6	37.5
	Not informed 3	18.8
Professional internship time of OT in hospital settings**	240 to 300hs 3	25
	301 to 400hs 4	33.3
	401 to 420hs 1	8.4
	Not informed 4	33.3

• ^*
  In 13 institutions that offered theoretical courses in hospital contexts, some courses mentioned and sent more than one menu, so the number of menus was 16.
• ^**
  Although 17 institutions offered vocational training in hospital contexts, only 12 menus were obtained.

Only part of the courses offered theoretical subjects in hospital contexts (54.2%), which vary between the minimum workload in 30 hours and the maximum in 75 hours, which is, on average, one offer of approximately 46 hours/semester, with a median of 45 hours.

Regarding the number of hours of vocational training in hospital contexts, there were at least 240 hours and 420 hours at the maximum offered, which involves an average of 332 hours/semester and a median of 367 hours.

Regarding the analysis of the total number of menus (n = 28), only 11 of them included aspects related to the study theme (Figure 2), passing contents through standard protocols, reporting, and recording in medical records (Table 2).

Figure 2
Summary of the analysis of the menus.

Table 2
Detailing the configuration of documentation information.

N = 05	Theorical Subjects
ET1	It did not show in the programmatic content, as well as in the bibliographical references, content linked to the documentation. However, in the activity schedule attached to the menu, there was a specific class on “Protocols for attendance in OT, ethical and professional posture, management, productivity indicators and registration in medical records”.
ET2	It was found only in the indication of the bibliographical reference of Resolution 415 of the COFFITO, about the registration in medical records by the occupational therapist.
ET3	As one of the topics of the programmatic content, it was the “treatment protocols in Occupational Therapy”.
	Unidentified texts on the topic are not identified in the bibliographical references.
ET4	The programmatic content showed “anamnesis procedures, planning, intervention, therapeutic activities, and reporting”.
	Unidentified texts on the topic are not identified in the bibliographical references.
ET5	As one of the objectives of teaching-learning, there was “to evaluate and monitor the patient's needs in hospital contexts through anamnesis, evaluative scripts, and standardized protocols”.
	Unidentified texts on the topic are not identified in the bibliographical references.
N=06	Professional Internship Subjects
EP6	The teaching program explained in one of its items “to elaborate reports and documentation of clinical pictures”, “to perform records of data and reports”.
	Unidentified texts on the topic are not identified in the bibliographical references.
EP7	“Drafting reports” were shown in the topic related to the activities to be developed by the student.
	Unidentified texts on the topic are not identified in the bibliographical references.
EP8	The teaching topic presented was “Records of procedures” and “Clinical Documentation”.
	The didactic procedure indicated was the “Guidance for the elaboration of the documentation of the process of Occupational Therapy”.
	“The record regarding individual or group occupational therapy intervention”, “the record of procedures performed by the hospital's TO service” and “reporting” were described as an activity of the trainee.
	Unidentified texts on the topic are not identified in the bibliographical references.
EP9	One of the objectives of the subject presented was “to enable the autonomous exercise for the preparation of registration in medical records and issuing reports”, “to enable the student to carry out records in a clear, ethical and complete way, stimulating the perception of documentary importance.”
	“Reporting and recording in medical records” were described as part of the activities to be developed by the student.
	Specific texts on clinical documentation and indication of resolution 415 of COFFITO were presented in the references which provide on the registration in medical records by the occupational therapist.
EP10	“Issue reports, opinions, medical certificate and reportings” were explained as one of the skills to be developed by the student.
	Unidentified texts on the topic are not identified in the bibliographical references.
EP11	“To elaborate evolutionary and revaluation reports with clear, objective technical language”, and “to keep records of attendance on time” were presented as part of the activities to be developed by the student.
	Unidentified texts on the topic are not identified in the bibliographical references.

• ET = menu of the theoretical subjects; EP = menu of the professional internship subjects.

From the menus that covered the theme of the study, 5 of them were on theoretical subjects in hospital contexts and 6 on a professional internship in hospital contexts, respectively.

From the theoretical subjects of hospital context, 3 menus included the presentation of protocols in their teaching topics and 2 covered the registration in medical records (1 mention in the class schedule along with other subjects and 1 only in references).

In the subjects of vocational training, 4 menus presented the registration on medical records as a student assignment. There was also a description in 4 of the menus about the issuance of reports but without specification of their purpose (academic report or medical report).

4 Discussion

The offer of theoretical courses on occupational therapy in hospital contexts is still reduced. This is a factor that denotes limitations in the teaching-learning process.

The lack or limited offer of theoretical contribution to the work of the occupational therapist in the hospital scope hinders practical learning. It is believed that the absence and inconsistencies in the offer of theoretical support restrict the development of the student in the area, given the contact for appropriation and correlation of innumerable contents (passing through equipment, procedures, pathologies, service dynamics and peculiarities of professional performance) sometimes occur exclusively in the professional internship.

There was an increase in the offer of professional internship in the hospital contexts when compared to the current indication of 17 courses of a sample of 24, in contrast to the study by Dahdah, Frizzo and Fangel (2014) that indicated the provision of internship in the hospital context for 12 courses in a sample of 33.

Despite the note regarding an increase in the offer of a professional internship in the hospital, it is worth remembering that some of the courses only part of the students participate in this activity. This configuration implies in the formation of students without experiences of theoretical subjects and of professional internship in the hospital.

In this way, it is questioned if this configuration of education allows in an effective way the discussion about the practice area, about the objectives of the intervention, as well as the construction of the skills and abilities to perform in the hospital (DAHDAH; FRIZZO; FANGEL, 2014).

It is emphasized that in the minimum standards for the education of occupational therapists, published by the World Federation Occupational Therapy - WFOT, there is a description of the need to develop the ability to execute work records and to acquire knowledge about the documentation that involves awareness of legislation and the confidentiality of information, among others (WORLD..., 2016).

Despite the importance of registration, a very small approach was observed in the national education about the registration in medical records in this study, obtaining indicators that show little supply of theoretical subsidies in this thematic and teaching-learning linked to the activities of professional internship in hospital contexts.

There is a theoretical fragility in the training process of the procedure of the registration in medical records since the findings evidenced, in particular in the menus, the record as attribution to be developed by the student in the area; however, it was a lack of basements such as the presentation of guidelines and models.

COFFITO Resolution nº 415 of May 19, 2012, regulates the minimum composition of the information in the medical record and explains guidelines on the process of keeping and discarding this document (CONSELHO…, 2012). However, as explored in the Bombarda (2014) study, there are occupational therapists who do not know it.

In this aspect, the documentary analysis showed that such resolution is also not presented in the graduation process in the hospital area, being the resolution referenced in subjects (1 theoretical subject and 1 professional internship subject) only by two courses. It is not our intention here to enter into the discussion about the content of the resolution, as well as whether it contemplates the practices of the different areas of action of occupational therapy or covers the singularities of the practice in the hospital context. At that moment, we sought only to identify if the teaching process involves the presentation of existing regulations.

The Subjective Objective Assessment Plan (SOAP), RMOP and Sequential Patient Care Record in Occupational Therapy-RSAPTO are examples of records models pointed out in the literature (MATTHEWS; JABRI, 2004), but they were not mentioned in documents evaluated as resources used in the process of teaching-learning. In this way, it is questioned that the presentation of instrumental bases could help in the favoring of the clinical reasoning and guiding the technical writing, minimizing the doubts of the students about what and how to register.

By the importance of vocational terminology, it is important to give an international action carried out by a project of the European Network of Occupational Therapy in Higher Education, composed of six countries (Austria, Belgium, Portugal, Spain, Switzerland and the United Kingdom) representing six different languages (German, Dutch, Portuguese, Spanish, French and English), which sought to structure a common terminology of the profession. This project culminated in the publication in 2010 of “The Core Concepts of Occupational Therapy: a Dynamic Reference for Practice”, presenting concepts established from key terms used by European occupational therapists to describe and explain their practices (CREEK, 2010).

In addition to the development of technical language in an interrelated way, pedagogical investments are necessary for the development of clinical reasoning. According to Marcolino (2017), clinical reasoning can be stimulated and developed within the formative process through the exercise of narrative writing, which constitutes a tool for explaining professional public discourse.

Although narrative writing is the most used model of record in occupational therapy (PANZERI, 2013; BOMBARDA, 2014), some studies (PIERRI, 2001; KIELHOFNER et al., 2004) point out that tensions related to medical records are due to the difficulty of professionals concisely report their actions on the narrative model, even though this is characteristic of the profession.

As the narrative characteristics are shown as a dilemma for occupational therapists, the professional public discourse composed by the writing of reports and registration in the medical record shows to be fragile, evidencing the need for investments in improvements in the process of initial and continuous training (MARCOLINO, 2017).

It is believed that the quality of clinical records is linked, among other things, to the students' rationale about the importance of records in care, management, research, and legal aspects. It is estimated that there is a direct relationship between knowledge about documentary importance and careful posture in the act of records, which means that the greater appropriation of the documentary value the student has, the more careful his attention will be in performing this procedure.

However, only the reasoning about the documentary importance does not guarantee the effectiveness of the learning and the quality of the registry, being necessary jointly the provision of other actions such as the presentation of scripts, models, guidelines and in particular, the stimulation of the development of the clinical reasoning and the appropriation of professional terminology, in an interrelated way.

5 Conclusion

This documentary study allowed the visualization of an initial panorama about the process of teaching the registration in medical records in the hospital contexts.

A small approach on the subject in the Brazilian teaching process and little indication of the presentation of fundamentals such as normative, registration models or scripts were found, a factor that may reflect on the quality of the notes and consequently weaken the professional public discourse.

Understanding that the process of teaching-learning involves actors and not just menus, some limitations of the study evidences the need to expand research on this subject, such as through the development of research involving the listening of teachers and students about the facilities and difficulties involved in teaching and learning about medical records and a deeper understanding of the resources and methodologies involved in this process. Nonetheless, it is also necessary to develop documentary research that proposes to directly analyze the occupational therapeutic registration of medical records in the hospital area to obtain indicators of performance and document quality.

Considering that the quality of the information recorded in medical records reflects in the production of scientific knowledge and in the public recognition of occupational therapeutic work, investments in the process of teaching-learning about the registration in medical records are instigated here.

• 1
  This paper is the presentation of partial data from the thesis “Medical records: understanding of the teaching-learning process in the framework of occupational therapy in hospital contexts”, developed in the UFSCar Postgraduate Program in Occupational Therapy.

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• POSSARI, J. F. Prontuário do paciente. In: POSSARI, J. F. Prontuário do paciente e os registros de enfermagem São Paulo: Látria, 2007. p. 17-34.
• WORLD FEDERATION OF OCCUPATIONAL THERAPY – WFOT. Minimum standards for the education of occupational therapists: revised 2016. London, 2016. Disponível em: <http://www.wfot.org/ResourceCentre/tabid/132/did/841/Default.aspx>. Acesso em: 25 abr. 2018.
  » http://www.wfot.org/ResourceCentre/tabid/132/did/841/Default.aspx

Publication Dates

• Publication in this collection
  29 Aug 2019
• Date of issue
  Jul-Sep 2019

History

• Received
  30 Apr 2018
• Reviewed
  23 Nov 2018
• Reviewed
  13 Mar 2019
• Accepted
  16 Apr 2019