ELECTRONIC PATIENT RECORD

HEALTH INFORMATION TECHNOLOGIES IN THE CONTEXT OF THE NATIONAL HEALTH INFORMATION AND INFORMATICS POLICY (NHIIP)

Abstract

This paper presents an excerpt from the dissertation “Electronic patient record: an information management strategy at Hospital Regional do Cariri” that aimed to verify whether the Hospital Regional do Cariri, in Juazeiro do Norte, Ceará, Brazil, uses the Electronic Record and Hospital Information Systems, with a view to optimizing Information Management in the face of the National Health Information and Informatics Policy (NHIIP) in the context of the Information Society. To this end, the work carried out a bibliographic review on the topics considered relevant for the construction of Information Management within the health units, addressing information concepts, and Information Management, focusing on the patient's electronic medical record as an effective management tool. It also discusses literature on health technologies, focusing on medical information management systems, from the perspective of PNIIS, with the purpose of clarifying the use of information and the computerization of health to improve the provision of services. It is characterized as an exploratory, descriptive, bibliographic research. The analysis of the results is based on the collection of information made through the questionnaires that were applied together with the doctors and the professionals who work in the hospital's archive, the Customer Service Center (CSC). The research exposes that PNIIS is not carried out within the Regional Hospital of Cariri, indicating aspects and processes to be improved within the unit, and proposes an Information Management policy, through the drafting of a manual, which provides guiding information for the application of a coherent and effective Information Management, according to the reality of the health unit.