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.“ in “In Guide to Medical Informatics” - Enrico Coiera