Desenvolvimento e implementação do prontuário eletrônico do paciente no Hospital São Paulo, hospital universitário da Unifesp
Data
2020
Autores
Vieira, Edvaldo Gomes 
Orientadores
Salvador, Maria Elisabete
Tipo
Dissertação de mestrado
Título da Revista
ISSN da Revista
Título de Volume
Resumo
A implantação do Prontuário Eletrônico do Paciente em serviços de saúde hospitalar é essencial para a gestão do cuidado e apoiar a tomada de decisão dos profissionais da área de saúde. Outrossim, mantê-lo atualizado é fundamental, por questões legais e clínicas. Objetivos: desenvolver e implantar o Prontuário Eletrônico do Paciente no Hospital São Paulo. Métodos: trata-se de um estudo tecnológico descritivo de abordagem quantitativa, ocorrido entre junho de 2017 a outubro de 2020. Por meio do banco de dados do Prontuário, realizou-se análise de navegabilidade por parte da equipe de saúde da referida instituição, a fim de obter dados relacionados ao acesso e uso. Metodologia de algoritmos e aprendizado de máquina representaram abordagens tecnológicas necessárias para compreender o cenário diário do Prontuário. Assim, as etapas metodológicas compreenderam: 1. Análise dos temas correlatos referente ao trabalho do profissional de saúde em prontuários. 2. Implantação do Prontuário na instituição supracitada. 3. Estudo da aplicação de Ciência de Dados a partir dos dados do Prontuário. 4. Aplicação de algoritmos de aprendizado de máquina. 5. Criação de proposta para nova arquitetura de trabalho do Prontuário. Resultados: as análises periódicas da utilização do Prontuário favoreceram estudo dos dados gerados promovendo discussão significativa para e equipe de saúde e desenvolvedores como nova forma de trabalhar com os dados do paciente. Foi possível avaliar a quantidade substancial de dados produzido pelo Prontuário e, com base nos resultados, analisar o quanto a utilização do Prontuário é vantajosa para a instituição. Também foi possível observar que a sua utilização promoveu melhorias relevantes para o processo de trabalho dos profissionais de saúde do hospital. Conclusão: o Prontuário tornou-se indispensável no atendimento ao paciente, gerando quantidade expressiva de dados para estudos e análises da gestão do cuidado. No período de produção desse estudo, o Prontuário foi desenvolvido, implantado e disponibilizado no hospital, obtendo-se análises dos processos como identificação das necessidades e recursos desenvolvidos.
The implementation of the Electronic Patient Record in hospital health services is essential for the management of care and supporting decision-making by health professionals. Also, keeping it updated is essential, for legal and clinical reasons. Aims: to develop and implement the Electronic Patient Record at Hospital São Paulo. Methods: this is a descriptive technological study with a quantitative approach, carried out between June 2017 and October 2020. Through the medical record database, a navigability analysis was carried out by the health team of that institution, the in order to obtain data related to access and usage. Algorithm methodology and machine learning represented the technological approaches needed to understand the daily scenario of the medical record. Thus, the methodological steps included: 1. Analysis of related themes related to the work of health professionals in medical records. 2. Implementation of the medical record in the aforementioned institution. 3. Study of the application of Data Science from the data in the medical record. 4. Application of machine learning algorithms. 5. Creation of a proposal for a new work architecture for the Prontuário. Results: the periodic analysis of the use of the medical record favored the study of the data generated, promoting a meaningful discussion for the health team and developers as a new way of working with patient data. It was possible to assess the substantial amount of data produced by the medical record and, based on the results, analyze how much the use of the medical record is advantageous for the institution. It was also possible to observe that its use promoted relevant improvements for the work process of the hospital's health professionals. Conclusion: the medical record has become essential in patient care, generating a significant amount of data for studies and analysis of care management. During the period of production of this study, the medical record was developed, implemented and made available in the hospital, obtaining analyzes of the processes such as identification of the needs and resources developed.
The implementation of the Electronic Patient Record in hospital health services is essential for the management of care and supporting decision-making by health professionals. Also, keeping it updated is essential, for legal and clinical reasons. Aims: to develop and implement the Electronic Patient Record at Hospital São Paulo. Methods: this is a descriptive technological study with a quantitative approach, carried out between June 2017 and October 2020. Through the medical record database, a navigability analysis was carried out by the health team of that institution, the in order to obtain data related to access and usage. Algorithm methodology and machine learning represented the technological approaches needed to understand the daily scenario of the medical record. Thus, the methodological steps included: 1. Analysis of related themes related to the work of health professionals in medical records. 2. Implementation of the medical record in the aforementioned institution. 3. Study of the application of Data Science from the data in the medical record. 4. Application of machine learning algorithms. 5. Creation of a proposal for a new work architecture for the Prontuário. Results: the periodic analysis of the use of the medical record favored the study of the data generated, promoting a meaningful discussion for the health team and developers as a new way of working with patient data. It was possible to assess the substantial amount of data produced by the medical record and, based on the results, analyze how much the use of the medical record is advantageous for the institution. It was also possible to observe that its use promoted relevant improvements for the work process of the hospital's health professionals. Conclusion: the medical record has become essential in patient care, generating a significant amount of data for studies and analysis of care management. During the period of production of this study, the medical record was developed, implemented and made available in the hospital, obtaining analyzes of the processes such as identification of the needs and resources developed.