Avaliação dos erros ou falhas de preenchimento dos atestados de óbito feitos pelos clínicos e pelos patologistas Comparison between death certificates filling errors or lack of filling fields done by pathologists and physicians

Abstract

INTRODUÇÃO: O preenchimento correto dos atestados de óbito (AO) é muito importante, porém geralmente negligenciado. OBJETIVO: Comparar os AO preenchidos pelos patologistas e pelos clínicos em relação à quantidade de erros de preenchimento e áreas não-preenchidas. MÉTODO: Foram comparados os atestados fornecidos pelo serviço de cardiologia do Hospital de Base (HB) e os das autópsias do Serviço de Verificação de Óbitos (SVO), de causas cardíacas, no ano de 2000, num total de 282 AO. Foi considerado erro ou falha de preenchimento quando os dados não correspondiam à verdade (p. ex.: item só para mulheres preenchido em paciente masculino) ou quando havia falta de preenchimento de algum item. RESULTADOS: Houve diferença em relação às médias das idades entre o grupo HB (67,8 anos) e o SVO (61,9 anos; p INTRODUCTION: The correct filling of Death Certificate (DC) is very important, however is usually neglected. OBJECTIVES: To compare DC filled by the pathologists and by the physicians, in relation to the number of mistakes and also the number of fields not filled. METHODS: We compared all DC filled by physicians from the Hospital de Base (HB) and DC filled by pathologists from the Pathology Department (PD), after autopsy procedure, during the year of 2000 (n = 282). A filling error was defined as an item not filled correct (ex.: only for women and filled in a male patient) or not filled at all. RESULTS: The mean age were different comparing HB group (67,8 years) and PD group (61,9 years; p < 0.01). In HB group none of the DC was completely filled, while in PD 11.92% were filled correctly (with all fields filled). However, 50 % of the HB filled DC had only one mistake and 7.6% had five or more errors, while in PD group 21.85% had five or more errors. In the items medical assistance, complementary exams and surgery of the DC, PD group had more non-filled fields than HB (p < 0.001). In relation to the item interval time of disease's evolution, no DC from HB group filled it, and just 31.7% of the pathologist's DC had it filled. Other kind of mistakes were observed and described. CONCLUSION: Pathologists had more fields not filled than the physicians did.

Keywords

• Autópsia
• Atestado de óbito
• Erros
• Autopsy
• Death certificate
• Errors