Resumo

VALDEZ MENDEZ, David. Safety tools for the patient: experience in the implementation of the electronic clinical file. Cir. gen [online]. 2011, vol.33, n.3, pp.146-150. ISSN 1405-0099.

Objective: To assess the impact of electronic health records on the patients' case histories in a private hospital. Setting: Hospital San Ángel Inn Chapultepec, 3^rd level, Mexico City. Design: Comparative, descriptive, retrospective, cross-sectional study. Statistical analysis: Descriptive statistics and Pearson's chi square test. Material and methods: Analysis of the clinical files recorded during 2010, divided in two groups: from January to March (without electronic means) and from October to December (with electronic means), assessed variables were: notes taken according to the Mexican Official Norm regarding the Clinical File, adequate filling out, readability, identification code, time and date of notes, signatures of writers, use of abbreviations, and the physical condition of the file. Results: A total of 2,416 files were analyzed; the first trimester (group A) with 1,182 and the fourth trimester (group B) with 1,234. An improvement was found in the filling out of the electronic health records, in time and date recordings, patient identification, signatures of physicians and nurses, readability, and the physical condition of the documents. No changes were observed in the elaboration of the informed consent and in the use of abbreviations. Finally, there were more deficiencies in the clinical history and the discharge summary when using electronic means. Conclusions: Although, in general, there was an improvement in the quality of the clinical recordings with electronic means, the use of abbreviations and incomplete filling of forms persisted, as well as a deficient elaboration of the clinical history, phenomena that depend on the activity of those that prepare these documents.

Palavras-chave : Electronic health records; safety for the patient.