Análise das informações no modulo de prontuários do AGHUX na unidade de atenção à saúde da criança e adolescente do HUPAA

Abstract

The patient's medical record is an important document for activities and professionals in the context of health institutions. It works as a database for research and teaching, as long as the ethical and legal aspects of access are respected. In addition, the data that constitute the medical record feed national health systems, producing indicators that support the creation and implementation of public policies for the health area. Therefore, it is required that the filling of the information that constitute the Patient's Medical Record to be accomplished in a clear, correct and complete way. This study aimed to analyze whether the information recorded in the Patient's Medical Record encounter the information required for professionals who use it in the Child and Adolescent Health Care Unit of the Professor Alberto Antunes University Hospital. In order to achieve the proposed objective, the information required for filling out the medical record was identified; from the perspective of professionals, their difficulties and perceptions regarding filling in or searching for information at the document were evidenced; the process of filling in the information contained in the chart was evaluated and the features of the Medical Records Management System were presented. The methodological approach of the research is a qualitative nature. The data collection instrument applied to professionals who use the Electronic Patient Record in the Hospital Unit was a questionnaire with open-ended and closedended questions. The data processing was carried out through the analysis of the results presented in the answers to the applied questionnaires. The study results showed that the lack of filling and/or incomplete filling of the information record in the Application de gestion pour les hôpitaux universitaires patient module, has already occurred in all fields consulted by professionals; regarding the difficulties on registering and retrieving information at the system, the suggestions for changes in the layout of the system's interface to facilitate registration and access to information, including shortcuts and some tools, stood out; the study also pointed out the system as practical, objective and facilitator of activities and communication in the work environment, but in contrast, some professionals consider it complex, presenting difficulties to access some information and; the need for more training for professionals about the usability of the system.