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Advisor(s)
Abstract(s)
Introdução: Actualmente, verifica-se que várias instituições de ensino superior de Medicina Dentária, estão a implementar registos clínicos electrónicos nas suas Clínicas Universitárias. Contudo, é frequente verificar a manutenção de um sistema híbrido ‘papel/electrónico’ pelo facto de se verificar uma falha de integração de dados no suporte electrónico. As necessidades de registo de dados clínicos ao nível das escolas de Medicina Dentária são diferentes e mais complexas do que as de uma prática clínica privada.
Objectivos: Analisar de que forma o registo clínico electrónico do programa de gestão clínica da Clínica Universitária da UCP [Newsoft DS9 (versão académica)®], representa o conteúdo existente nos registos clínicos em papel de todas as áreas disciplinares clínicas.
Materiais e Métodos: Numa primeira fase, verificou-se de que forma as áreas disciplinares clínicas registam os respectivos dados clínicos (suporte papel / suporte electrónico / suporte híbrido). De seguida, analisaram-se e registaram-se todos os campos existentes nos registos clínicos em papel das várias áreas disciplinares, de forma a criar um registo clínico geral que se designou de “Baseline Dental Record - BDR”. Todos os campos presentes nos vários registos clínicos em papel foram extraídos e categorizados. Foram excluídos os campos que duplicavam o formato e conteúdo de outros campos. Foram também analisados, registados e categorizados os campos existentes no registo clínico electrónico do programa de gestão clínica Newsoft DS9®. Por último, a informação contida nos registos clínicos em papel, foi mapeada com os campos existentes no registo clínico electrónico do programa Newsoft DS9®.
Resultados: Foram registados um total de 183 campos dos registos clínicos em papel. No registo clínico electrónico contabilizaram-se 75 campos, representando 41% dos dados contidos nos registos clínicos em papel. Com esta migração para o Newsoft DS9® as áreas disciplinares que menos dados para registo têm são: Oclusão (23,1%), Ortodontia (23,8%) e Prótese Fixa (29,4%). Por outro lado as áreas disciplinares mais representadas no Newsoft DS9® são: Medicina Oral (93,3%), Dentisteria Operatória (76,9%) e Odontopediatria (69,6%).
Conclusão: O registo clínico electrónico do programa de gestão clínica da Clinica Universitária da UCP (Newsoft DS9®), apenas representa 41% do conteúdo existente nos registos clínicos em papel de todas as áreas disciplinares clínicas. É necessário investigar as razões desta diferença e avaliar as necessidades de actualização do registo clínico electrónico em investigações futuras
Introduction: Currently, it appears that many institutions of higher education in dentistry are implementing electronic health records in their University Clinics. However, it is frequently check the maintenance of a hybrid system "paper /electronic ' because of verifying a failure of integration of data in electronic format. The requirements for registration of clinical data at the level of schools of dentistry are different and more complex than those of a private clinical practice Objectives: Analyze how the electronic medical record program management clinic at the UCP University Clinic [Newsoft DS9 (academic version) ®], represents the existing content in the paper medical records of all clinical disciplines. Material and Methods: Initially, it was noted how the disciplines clinical record their clinical data (paper / electronic / hybrid support). Then looked up and there were all the fields in the existing paper medical records from various disciplines in order to create a record that was appointed general practitioner of "Baseline Dental Record - BDR". All fields present in the various medical records on paper were extracted and categorized. We excluded fields which duplicate the format and contents of other fields. Were also analyzed, recorded and categorized the existing fields in the electronic medical record management program clinical Newsoft DS9®. Finally, the information contained in the medical records on paper was mapped with existing fields in the electronic medical record program Newsoft DS9®. Results: Were reported a total of 183 fields from medical records on paper. In the electronic medical record with 75 fields counted, representing 41% of the data contained in the medical records on paper. With this migration to Newsoft DS9® subject areas that have less data to record are: Occlusion (23.1%), Orthodontics (23.8%) and Fixed Prosthodontics (29.4%). On the other hand most subject areas are represented in Newsoft DS9®: Oral Medicine (93.3%), Operative Dentistry (76.9%) and Pediatric Dentistry (69.6%). Conclusion: The electronic medical record program management clinic of the UCP University Clinic (Newsoft DS9®) represents only 41% of the content in the paper medical records of all clinical disciplines. It is necessary to investigate the reasons for this difference and assess the needs for updating the electronic clinical record in future investigations.
Introduction: Currently, it appears that many institutions of higher education in dentistry are implementing electronic health records in their University Clinics. However, it is frequently check the maintenance of a hybrid system "paper /electronic ' because of verifying a failure of integration of data in electronic format. The requirements for registration of clinical data at the level of schools of dentistry are different and more complex than those of a private clinical practice Objectives: Analyze how the electronic medical record program management clinic at the UCP University Clinic [Newsoft DS9 (academic version) ®], represents the existing content in the paper medical records of all clinical disciplines. Material and Methods: Initially, it was noted how the disciplines clinical record their clinical data (paper / electronic / hybrid support). Then looked up and there were all the fields in the existing paper medical records from various disciplines in order to create a record that was appointed general practitioner of "Baseline Dental Record - BDR". All fields present in the various medical records on paper were extracted and categorized. We excluded fields which duplicate the format and contents of other fields. Were also analyzed, recorded and categorized the existing fields in the electronic medical record management program clinical Newsoft DS9®. Finally, the information contained in the medical records on paper was mapped with existing fields in the electronic medical record program Newsoft DS9®. Results: Were reported a total of 183 fields from medical records on paper. In the electronic medical record with 75 fields counted, representing 41% of the data contained in the medical records on paper. With this migration to Newsoft DS9® subject areas that have less data to record are: Occlusion (23.1%), Orthodontics (23.8%) and Fixed Prosthodontics (29.4%). On the other hand most subject areas are represented in Newsoft DS9®: Oral Medicine (93.3%), Operative Dentistry (76.9%) and Pediatric Dentistry (69.6%). Conclusion: The electronic medical record program management clinic of the UCP University Clinic (Newsoft DS9®) represents only 41% of the content in the paper medical records of all clinical disciplines. It is necessary to investigate the reasons for this difference and assess the needs for updating the electronic clinical record in future investigations.
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Keywords
Registo clínico electrónico Registo clínico em papel Informática médica Comparação de registos Newsoft DS9® Baseline dental recorder Computer-based patient records Paper-based patient records Medical informatics Records comparation Newsoft DS® Baseline dental recorder