Melhorando o atendimento ao paciente através de registros eletrônicos: um olhar para a implementação de um prontuário eletrônico em um hospital de alta complexidade.

Abstract

The Electronic Patient Record (PEP) is currently the safest method for recording clinical information during hospitalization. This study aimed to evaluate the flow of information from patient records for the use of an Electronic Patient Record as well as the use of computerized tools in a High Complexity Hospital in Maranhão. This is an observational and interventional study carried out in a highly complex hospital in the city of Coroatá, in the interior of Maranhão. The unit's workflows were observed, where records were made manually from admission to discharge. The Klinikos and GMed system were adopted as implementation of the PEP. Sectors without computers with internet access and professionals who did not adapt to the implementations did not achieve the objective of the study. The reception and hospitalization sectors were observed, of which only the two Adult Intensive Care Units and the Medical Clinic were able to fully implement the available tools. Professionals in the intermediate age group (31 to 40 years old) were those who became most familiar with the systems, accounting for 48%. Furthermore, a lack of equipment for implementing the PEP was observed in sectors, however 63% of professionals who have access to the PEP reported that their sector always has access to a computer and system. The implementation of PEP demonstrated greater agility in the provision of care and security in the electronic storage and accessibility of documents, such as medical prescriptions. For complete implementation in the unit, it is necessary to invest in staff training and in the acquisition of equipment for the deficient sectors and greater involvement of medical professionals.