Integración de las listas de problemas de los registros médicos de diferentes niveles de atención

LUNA, DANIEL R.; MAURO, ALEJANDRO; BENÍTEZ, SONIA E.; BAUM, ANALÍA J.; OTERO, PAULA; GAMBARTE, MARIA LAURA; GÓMEZ, ADRIÁN R.; GONZÁLEZ, B. DE QUIRÓS F.

Congreso; XCBIS 2006 - X Congreso Brasileiro de Informática em Saúde; 2006

La historia clínica es esencial en la atención en salud y sirve de nexo entre médicos y servicios. Su estructuración depende, entre otras cosas del nivel de atención. A su vez, la orientación a problemas, brinda una estructura interna que está dada por la lista de problemas, destacándose su utilidad cuando se aplica esta estrategia a historias clínicas electrónicas. En 1998 la informatización del registro médico del Hospital Italiano, comenzó con el nivel ambulatorio y continuó con la internación y la guardia, manteniendo la orientación a problemas del registro ambulatorio. Abstract ? The medical record is an essential issue in health care delivery and serves as nexus between physicians and other healthcare providers. Its structuring depends, among other things, of the type of health care delivered like outpatient or inpatient. In addition, problem orientation has a core structure given by the problem list, whose benefits are increased by the electronic medical record. On 1998 the Hospital Italiano de Buenos Aires started the development of a problem oriented electronic medical record for primary care, followed by inpatient and emergency care trying to keep the problem oriented record. Since inpatient and emergency care behave as episodic types of care, the challenge was to create a single repository for the patients' problem list. This repository links each level of care, giving the opportunity of retrieving and updating the patient's record, avoiding the duplication of problems. A unique problem list for each patient provides a useful tool for the developing of clinical decision support systems.