Standardization of Electronic Medical Records of Patients

Abstract

INTRODUCTION: to create a medical record for use specifies a breast cancer specialist, as recommended by the Federal Council of Medicine (CFM) and the Brazilian Society of Health Informatics (SBIS). We analyzed the recommendations of the CFM, SBIS and Brazilian Mastology (SBM), grounded in the relevant legal issues, in order to standardize and implement an Electronic Medical Record Medical facing the Specialty Mastology that would meet these norms, it was feasible and mainly accessible and practical for its users. We analyzed the recommendations of the CFM, SBIS and Brazilian Mastology (SBM), grounded in the relevant legal issues, in order to standardize and implement an Electronic Medical Record Medical facing the Specialty Mastology that would meet these norms, it was feasible and mainly accessible and practical for its users. MATERIALS AND METHODS: The authors institution has released some years ago developed software to replace paper medical records for “Electronic Patient Record” (PEP) in order to collect, manage, deliver and streamline the care of their customers. The selected software has been used by all medical specialties of the institution, in a tertiary care hospital of high complexity, by doctors from different profiles, knowledge and computer skills. The authors comment regarding the clear under-utilizing the potential of the software, plus a few scattered attempts mastologists, including this motivated to evaluate the feasibility of adapting existing programs, facilitating access to, more familiar to many users, which could be easily used and available to mastologists in their daily practice. RESULTS: Based on the author s experience, which uses 11 years ago, in his private clinic, PEP, the recommendations of the SBIS and CFM 1 2, we assessed how best to optimize the tools available, based on assumptions of a PEP 3: Standardized set of documents, ordered and concise, for the registration of medical care provided to patients and pramedicos; DISCUSSION: The results of the evaluation of software in focus showed that none met the prerequisites set out by legal entities normalizing of PEPs and / or did not attend the items proposed by the author (low cost, easy, friendly interface, compatibility with various operating systems, integration with virtual servers, sharing between groups, accessibility for the patient, “paper-free”, research support). CONCLUSION: Though we live in an era entirely digital, we see no resistance from medical professionals, but more from lack of stimulation, the use of paper records, letters with illegible prescriptions, big waste of time to fill the various documents and forms, increased risk of proceedings for lack of documentation of medical acts performed. In addition, the virtualization of information, where much of human knowledge is available “in cloud”, this gap in the medical field with the exponential progress of computer technology can only be deleted if the class entities in the specific case, SBM, take upon itself the role to develop and offer a practical tool for everyday use of mastologists, which will bring in its wake a huge differential, which is the formation of a giant database “online” and “on-time “.