Abstract
To present and validate a multifunctional electronic medical record (EMR) for outpatient care to women with endocrine disorders in pregnancy and to compare health information data fill rate to conventional medical records. We developed an EMR named Ambulatory of Endocrine Diseases in Pregnancy (AMBEG) for systematic registration of health information The AMBEG was used for obstetric and endocrine care in a sample of pregnant women admitted to the maternity reference in high-risk pregnancies in Bahia from January 2010 to December 2013. We randomly selected 100 patients accompanied with AMBEG and 100 patients monitored with conventional consultation and compared the health information data fill rate of the electronic consultation to that performed using conventional medical records. 1461 consultations were held, of which 253, 963 and 245 were first, follow-up and puerperium consultations, respectively. Most patients were pregnant women with diabetes (77.2%) and 60.1% were women with pre-gestational diabetes. The AMBEG satisfactorily replaced the conventional medical record. The percentage of registered information was significantly higher in the AMBEG: clinical symptoms (87% versus 100, p < 0.01), uterine height (89 versus 75%, p = 0.01), total weight gain (91 versus 40%, p < 0.01) and specific diabetes data (diet, insulin regimen, glycemic control and management of hypoglycemia) revealed a significant difference (p < 0.01). The ability to export data to worksheets greatly facilitated and accelerated the statistical analysis of the data. AMBEG is a useful tool in clinical care for women with endocrine diseases during pregnancy. The fill rate of clinical information was superior to that registered in conventional medical records.
Highlights
Magalhães Netto, Salvador, BA, Brasil 3 Residência de Obstetrícia da Maternidade Prof José Maria de Magalhães Netto, Salvador, BA, Brasil
O percentual de informações clínicas registradas em ambos os prontuários foi significativamente maior no Ambulatório de Endocrinopatias na Gestação eletrônico (AMBEG): queixas clínicas (100 versus 87%, p < 0,01), altura uterina (89 versus 75%, p 1⁄4 0,01), ganho de peso total (91 versus 40%, p < 0,01) e dados específicos sobre o diabetes revelando diferença significativa (p < 0,01)
We developed an electronic medical record (EMR) named Ambulatory of Endocrine Diseases in Pregnancy (AMBEG) for systematic registration of health information The AMBEG was used for obstetric and endocrine care in a sample of pregnant women admitted to the maternity reference in high-risk pregnancies in Bahia from January 2010 to December 2013
Summary
Magalhães Netto, Salvador, BA, Brasil 3 Residência de Obstetrícia da Maternidade Prof José Maria de Magalhães Netto, Salvador, BA, Brasil. Objetivo Apresentar e validar um registro eletrônico de saúde (RES) multifuncional para atendimento ambulatorial a portadoras de endocrinopatias na gestação e comparar a taxa de preenchimento de informações de saúde com o prontuário convencional.
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