Abstract
Objective: To create an instrument that allows the classification of the quality of patient admission records in urgency and emergency units, verifying the most omitted and most evaluated items when filling out medical records. Methods: Methodological study, which qualitatively analyzed printed material from 1195 electronic medical records collected in a private urgent and emergency institution in Northeastern Brazil. A sample was used for the convenience of medical records of patients aged 18 years or older and those who did not undergo medical evaluation were excluded. The collected medical records were evaluated by the proposed instrument, according to the items: identification, characterization of the main complaint, allergies, medications in use, personal pathological history and pregnancy, last meal, reason and time of admission, general condition and physical examination. Results: In the final classification proposed by the instrument, 88 complete medical records, 773 basic and 334 insufficient ones were obtained. When analyzing the data collected in this study, a flaw in the construction of medical records was evident, mainly in the items general condition, last meal, medications in use, allergies, and personal history. Conclusion: Therefore, it becomes relevant to use a specific instrument for the evaluation and classification of medical records, optimizing patient care, diagnosis, and prognosis, and protecting all those involved in the judicial sphere.