Resumo

LOPEZ, Jaime Alberto et al. Development of a record-keeping strategy for improvement of information retention in microbiological processing. Biomédica [online]. 2004, vol.24, n.3, pp.318-323. ISSN 0120-4157.

The improvement of microbiological information processing in clinical laboratories depends on retention of information concerning who, what, when, how, and why each process was performed, the implementation of quality control procedures, and finally, its evaluation. The four objectives to be addressed are as follows: (1) to improve the collection of information concerned with microbiological processes, (2) to evaluate results of implemented strategies, (3) to offer a model data base to be used in research projects, and (4) to propose an evaluation model for comparative studies. To do this, microbiological cultures were collected from hospitalized patients from June 1997 to June 2003. Data for the analytical matrix were obtained from lab requests, medical history and the microbiological data. Statistical analyses were performed in Epi-Info 6. The laboratory records for 46,072 microbiological cultures were analyzed. Completion levels in data collection were compared between years 1997 and 2003. Samples from 1997 and 2003 showed 11% and 99% of the request forms specifically requesting microbiological culture, 11% and 99% were completed in 1997 and 2003, respectively. For the same years, 9% and 85% specifically stated the time of the request. Ten percent and 68%, respectively, provided complete information. Zero and 83% respectively stated who had collected the sample. Zero and 77%, respectively, specified the time of sample collection. Forms containing all relevent microbiological data were most complete with 78% and 96%, respectively. A database with 44 variables related to microbiological processes was created. In conclusion, improvement of microbiological data processing depends not only on the method of collection and completion of recorded information, but also on constant quality control and evaluation.

Palavras-chave : medical records; databases; clinical informatics; data formats; data collection.

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