A Single Process

• Autor(a) principal: Moraes, Maria Francisca
• Data de Publicação: 2001
• Outros Autores: Pimenta, José M.
• Tipo de documento: Artigo
• Idioma: por
• Título da fonte: Repositório Científico de Acesso Aberto de Portugal (Repositórios Cientìficos)
• Texto Completo: https://revista.spmi.pt/index.php/rpmi/article/view/1953
• topic: processo clínico; processo único integrado; gestão de informação; medical records; integrated medical record; information management

A correct and complete documentation of patientdata is essential for good medical practice. The bestuse of health resources, an adequate perception ofthe clinical situation and patient satisfaction can onlybe achieved through information exchange betweenthe health professionals responsible for patient care.Traditionally there is a separation between medical records in the Health Center and in the Hospital. Inthe more developed countries, as far as health careorganization is concerned, efforts are progressingto link information in the so-called IntegratedClinical Patient Notes. In direct contrast, in somecentral Portuguese Hospitals, we are still at the stageof linking information pertaining to the severalHospital Admissions and Consultations of aparticular patient in the same Hospital. Examplesof daily problems related to patient clinical notes inthe Emergency Service and at the time of HospitalAdmission are reported and suggestions are made for their resolution