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

Bombarda, Tatiana Barbieri; Joaquim, Regina Helena Vitale Torkomian

doi:10.4322/2526-8910.ctoAO1714

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Original Article • Cad. Bras. Ter. Ocup. 27 (3) • Jul-Sep 2019 • https://doi.org/10.4322/2526-8910.ctoAO1714 copy

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

Authorship SCIMAGO INSTITUTIONS RANKINGS

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

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
Theoretical subjects offer of OT in hospital contexts	No 11	45.8
Professional internship offer of OT in hospital contexts	Yes 17	70.8
Professional internship offer of OT in hospital contexts	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^* * 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.	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^ Although 17 institutions offered vocational training in hospital contexts, only 12 menus were obtained.	240 to 300hs 3	25
	301 to 400hs 4	33.3
	401 to 420hs 1	8.4
	Not informed 4	33.3

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”.
ET3	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”.
ET4	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”.
ET5	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”.
EP6	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.
EP7	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.
EP10	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.
EP11	Unidentified texts on the topic are not identified in the bibliographical references.

Universidade Federal de São Carlos, Departamento de Terapia Ocupacional Rodovia Washington Luis, Km 235, Caixa Postal 676, CEP: , 13565-905, São Carlos, SP - Brasil, Tel.: 55-16-3361-8749 - São Carlos - SP - Brazil
E-mail: cadto@ufscar.br

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[1] Corresponding author: Tatiana Barbieri Bombarda, Departamento de Terapia Ocupacional, Universidade Federal de São Carlos, Rod. Washington Luiz, Km 235, CEP 13565-905, São Carlos, SP, Brasil, e-mail: tatibb_to@yahoo.com.br