Registos clínicos electrónicos

Os registos clínicos / prontuários electrónicos são uma parte fundamental do conjuntos dos sistemas de informação de qualquer instituição de saúde.

São uma nova forma de encarar os Registos Clínicos, e devem ser capazes de permitir uma evolução clara em relação aos Registos Clínicos em Papel.

Definições

Electronic medical record

A general term describing computer-based patient record systems. It is sometimes extended to include other functions like order entry for medications and tests, amongst other common functions. What does an electronic medical record (EMR) do? For many it is much more than an electronic replacement of existing paper systems. The EMR can start to actively support clinical care by providing a wide variety of information services. However, it is hard to understand what information is really important to clínical care, and what is simply occasionaly desirable.“

Importância

“Health-care organizations, finding that they do not have adequate systems for answering questions crucial to strategic planning and for remaining competitive with other provider groups, are looking to information technologies for help.

Many institutions are developing integrated clinical workstations, which provide a single point of entry for access to patient-related, administrative, and research information.

At the heart of the evolving clinical workstation lies the medical record in a new incarnation: electronic, accessible, confidential, secure, acceptable to clinicians and patients, and integrated with other, non-patient-specific information.” in “The evolution of Electronic Medical Records” – EH Shortliffe