Avaliação comparativa do conteúdo dos registos clínicos da Clínica Universitária da UCP em suporte papel vs suporte electrónico

Activity: Supervision

Description

Introduction: Currently, it appears that many institutions of higher education in dentistry are implementing electronic health records in their University Clinics. However, it is frequently check the maintenance of a hybrid system "paper /electronic ' because of verifying a failure of integration of data in electronic format. The requirements for registration of clinical data at the level of schools of dentistry are different and more complex than those of a private clinical practice Objectives: Analyze how the electronic medical record program management clinic at the UCP University Clinic [Newsoft DS9 (academic version) ®], represents the existing content in the paper medical records of all clinical disciplines. Material and Methods: Initially, it was noted how the disciplines clinical record their clinical data (paper / electronic / hybrid support). Then looked up and there were all the fields in the existing paper medical records from various disciplines in order to create a record that was appointed general practitioner of "Baseline Dental Record - BDR". All fields present in the various medical records on paper were extracted and categorized. We excluded fields which duplicate the format and contents of other fields. Were also analyzed, recorded and categorized the existing fields in the electronic medical record management program clinical Newsoft DS9®. Finally, the information contained in the medical records on paper was mapped with existing fields in the electronic medical record program Newsoft DS9®. Results: Were reported a total of 183 fields from medical records on paper. In the electronic medical record with 75 fields counted, representing 41% of the data contained in the medical records on paper. With this migration to Newsoft DS9® subject areas that have less data to record are: Occlusion (23.1%), Orthodontics (23.8%) and Fixed Prosthodontics (29.4%). On the other hand most subject areas are represented in Newsoft DS9®: Oral Medicine (93.3%), Operative Dentistry (76.9%) and Pediatric Dentistry (69.6%). Conclusion: The electronic medical record program management clinic of the UCP University Clinic (Newsoft DS9®) represents only 41% of the content in the paper medical records of all clinical disciplines. It is necessary to investigate the reasons for this difference and assess the needs for updating the electronic clinical record in future investigations.
PeriodSep 2012
Degree of RecognitionMaster

Keywords

  • Computer-based patient records
  • Paper-based patient records
  • Medical informatics
  • Records comparation
  • Newsoft DS®
  • Baseline dental recorder