Medical Records History: Evolution of Traditional Medical Records to Electronic Patient Record – PEP

• Autor(a) principal: Silva, Cristiane Rodrigues da
• Data de Publicação: 2021
• Tipo de documento: Artigo
• Idioma: por
• Título da fonte: Research, Society and Development
• DOI: 10.33448/rsd-v10i9.18031
• Texto Completo: https://rsdjournal.org/index.php/rsd/article/view/18031
• topic: Patients; Health; Electronic medical records.; Pacientes; Salud; Historia clínica electrónica.; Pacientes; Saúde; Prontuário eletrônico.

The objective of this research is to analyze what has been produced in the field of medical record history and its evolution from its emergence with the traditional medical record to the present day with the electronic patient record (PEP) and its implementation and use in the period from 2010 to 2019, through bibliographical and descriptive research, identifying in the literature about the history of the medical record and its evolution. The Virtual Health Library, LILACS database, and SciELO electronic libraries were used. The descriptors used were “Analysis of the Electronic Patient Record (EPR)”; “Patients” and “Health”. As a result, it can be observed that the innovation of the Medical Record through the PEP is closely linked to the involvement of users in their planning for their success or failure. It is concluded that this user is also very concerned and is very careful with the fact that information technology may or may not eliminate contact with the patient.