Prontuário eletrônico do paciente: vantagens e desafios na implementação

Abstract

This study aimed to implement the Electronic Patient Record (PEP) in order to integrate the care provided by professionals in a 24-hour Basic Health Unit (UBS) in the city of Campo Magro (PR), Metropolitan Region of Curitiba (PR). This is an observational, descriptive, quantitative and cross-sectional study, in which 28 health professionals participated. Two questionnaires were applied for data collection, the first consisting of ten and the second of 15 questions, obtaining five answers, and then the results were analyzed using the Kruskal-Wallis and Mann-Whitney tests. The work was approved by the Research Ethics Committee at UTFPR. In the results, it was noted that 18 professionals (64.29%) were female, between 18 and 30 years old, with higher education. The professional class with the greatest participation in the study was the physician, with 12 (46.43%). The majority, 17 (69.71%), had partial knowledge of information technology and 26 (71.43%) used electronic devices in their daily routine. The training was informative enough for 25 (89.28%) of the studied group; the same percentage believed they had received the necessary tools to use the PEP. However, seven (25%) of respondents reported some difficulty with the use of electronic medical records. Professionals with a higher level of education, knowledge of computers and use of electronic technologies showed greater ease in terms of training, information and adequacy. The PEP improved patient care, according to 23 (82.14%) of the respondents. The study proved to be relevant for the computerization of the UBS, for patient safety, carrying out audits, optimizing data files, agility in the ombudsman, as a subsidy for future research and integration of the services provided. Thus, it is concluded that although there are difficulties, the use of electronic medical records and software in general brings advances to the health system, requiring further research to consolidate the implementation of the PEP across the country, as well as improve health care of the population.