Family practice records are in danger

Bibliographic Details
Main Author: Granja, Mónica
Publication Date: 2018
Format: Article
Language: por
Source: Repositórios Científicos de Acesso Aberto de Portugal (RCAAP)
Download full: https://doi.org/10.32385/rpmgf.v34i1.12361
Summary: Medical records are a key element of health care delivery. Records written by Portuguese family physicians often contain incomplete baseline information, progressive replacement of clinical notes by items of the International Classification of Primary Care, problems that are not listed according to their highest level of resolution and lists of problems that are neither complete nor a rigorous clinical summary of the patient. Limitations of the software ‘SClínico Cuidados de Saúde Primários’ may explain these problems on medical records. This application is not compatible with the Problem-Oriented Medical Record; on the other hand, it forces the use of the International Classification of Primary Care before the entry of actual clinical notes. Imposed performance indicators may also be another possible explanation. Family physicians must persist in the quality of their records and take an active part in the development of electronic health record systems, keeping them centred on the patient and on health care delivery.
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spelling Family practice records are in dangerOs registos dos médicos de família estão em perigoFamily practiceMedical recordsProblem-oriented medical recordsElectronic health records.Medicina geral e familiarRegistos médicosRegisto Médico Orientado por ProblemasRegistos clínicos eletrónicos.Medical records are a key element of health care delivery. Records written by Portuguese family physicians often contain incomplete baseline information, progressive replacement of clinical notes by items of the International Classification of Primary Care, problems that are not listed according to their highest level of resolution and lists of problems that are neither complete nor a rigorous clinical summary of the patient. Limitations of the software ‘SClínico Cuidados de Saúde Primários’ may explain these problems on medical records. This application is not compatible with the Problem-Oriented Medical Record; on the other hand, it forces the use of the International Classification of Primary Care before the entry of actual clinical notes. Imposed performance indicators may also be another possible explanation. Family physicians must persist in the quality of their records and take an active part in the development of electronic health record systems, keeping them centred on the patient and on health care delivery.Os registos médicos são uma peça chave da prestação de cuidados de saúde. Nos registos dos médicos de família portugueses encontram-se frequentemente dados base muito incompletos, a substituição de notas clínicas progressivas por itens da Classificação Internacional de Cuidados Primários, problemas que não são listados ao seu mais alto nível de resolução e listas de problemas que não servem como resumo completo e rigoroso do paciente. Limitações da aplicação informática «SClínico Cuidados de Saúde Primários» podem ser uma explicação para estes problemas com os registos. Esta aplicação, por um lado, não é compatível com o Registo Médico Orientado por Problemas; por outro, força ao uso da Classificação Internacional de Cuidados Primários antes do registo propriamente dito. Imposições na avaliação de desempenho das unidades de saúde são outra possível explicação. Os médicos de família precisam de investir na qualidade dos seus registos e de participar no desenvolvimento das respetivas aplicações informáticas, mantendo-os centrados no paciente e nos cuidados a prestar.Associação Portuguesa de Medicina Geral e Familiar2018-02-01info:eu-repo/semantics/publishedVersioninfo:eu-repo/semantics/articleapplication/pdfhttps://doi.org/10.32385/rpmgf.v34i1.12361https://doi.org/10.32385/rpmgf.v34i1.12361Portuguese Journal of Family Medicine and General Practice; Vol. 34 No. 1 (2018): Revista Portuguesa de Medicina Geral e Familiar; 33-9Revista Portuguesa de Medicina Geral e Familiar; Vol. 34 Núm. 1 (2018): Revista Portuguesa de Medicina Geral e Familiar; 33-9Revista Portuguesa de Medicina Geral e Familiar; Vol. 34 N.º 1 (2018): Revista Portuguesa de Medicina Geral e Familiar; 33-92182-51812182-517310.32385/rpmgf.v34i1reponame:Repositórios Científicos de Acesso Aberto de Portugal (RCAAP)instname:FCCN, serviços digitais da FCT – Fundação para a Ciência e a Tecnologiainstacron:RCAAPporhttps://rpmgf.pt/ojs/index.php/rpmgf/article/view/12361https://rpmgf.pt/ojs/index.php/rpmgf/article/view/12361/11414Direitos de Autor (c) 2018 Revista Portuguesa de Medicina Geral e Familiarinfo:eu-repo/semantics/openAccessGranja, Mónica2024-09-17T12:00:12Zoai:ojs.rpmgf.pt:article/12361Portal AgregadorONGhttps://www.rcaap.pt/oai/openaireinfo@rcaap.ptopendoar:https://opendoar.ac.uk/repository/71602025-05-28T18:52:34.129999Repositórios Científicos de Acesso Aberto de Portugal (RCAAP) - FCCN, serviços digitais da FCT – Fundação para a Ciência e a Tecnologiafalse
dc.title.none.fl_str_mv Family practice records are in danger
Os registos dos médicos de família estão em perigo
title Family practice records are in danger
spellingShingle Family practice records are in danger
Granja, Mónica
Family practice
Medical records
Problem-oriented medical records
Electronic health records.
Medicina geral e familiar
Registos médicos
Registo Médico Orientado por Problemas
Registos clínicos eletrónicos.
title_short Family practice records are in danger
title_full Family practice records are in danger
title_fullStr Family practice records are in danger
title_full_unstemmed Family practice records are in danger
title_sort Family practice records are in danger
author Granja, Mónica
author_facet Granja, Mónica
author_role author
dc.contributor.author.fl_str_mv Granja, Mónica
dc.subject.por.fl_str_mv Family practice
Medical records
Problem-oriented medical records
Electronic health records.
Medicina geral e familiar
Registos médicos
Registo Médico Orientado por Problemas
Registos clínicos eletrónicos.
topic Family practice
Medical records
Problem-oriented medical records
Electronic health records.
Medicina geral e familiar
Registos médicos
Registo Médico Orientado por Problemas
Registos clínicos eletrónicos.
description Medical records are a key element of health care delivery. Records written by Portuguese family physicians often contain incomplete baseline information, progressive replacement of clinical notes by items of the International Classification of Primary Care, problems that are not listed according to their highest level of resolution and lists of problems that are neither complete nor a rigorous clinical summary of the patient. Limitations of the software ‘SClínico Cuidados de Saúde Primários’ may explain these problems on medical records. This application is not compatible with the Problem-Oriented Medical Record; on the other hand, it forces the use of the International Classification of Primary Care before the entry of actual clinical notes. Imposed performance indicators may also be another possible explanation. Family physicians must persist in the quality of their records and take an active part in the development of electronic health record systems, keeping them centred on the patient and on health care delivery.
publishDate 2018
dc.date.none.fl_str_mv 2018-02-01
dc.type.status.fl_str_mv info:eu-repo/semantics/publishedVersion
dc.type.driver.fl_str_mv info:eu-repo/semantics/article
format article
status_str publishedVersion
dc.identifier.uri.fl_str_mv https://doi.org/10.32385/rpmgf.v34i1.12361
https://doi.org/10.32385/rpmgf.v34i1.12361
url https://doi.org/10.32385/rpmgf.v34i1.12361
dc.language.iso.fl_str_mv por
language por
dc.relation.none.fl_str_mv https://rpmgf.pt/ojs/index.php/rpmgf/article/view/12361
https://rpmgf.pt/ojs/index.php/rpmgf/article/view/12361/11414
dc.rights.driver.fl_str_mv Direitos de Autor (c) 2018 Revista Portuguesa de Medicina Geral e Familiar
info:eu-repo/semantics/openAccess
rights_invalid_str_mv Direitos de Autor (c) 2018 Revista Portuguesa de Medicina Geral e Familiar
eu_rights_str_mv openAccess
dc.format.none.fl_str_mv application/pdf
dc.publisher.none.fl_str_mv Associação Portuguesa de Medicina Geral e Familiar
publisher.none.fl_str_mv Associação Portuguesa de Medicina Geral e Familiar
dc.source.none.fl_str_mv Portuguese Journal of Family Medicine and General Practice; Vol. 34 No. 1 (2018): Revista Portuguesa de Medicina Geral e Familiar; 33-9
Revista Portuguesa de Medicina Geral e Familiar; Vol. 34 Núm. 1 (2018): Revista Portuguesa de Medicina Geral e Familiar; 33-9
Revista Portuguesa de Medicina Geral e Familiar; Vol. 34 N.º 1 (2018): Revista Portuguesa de Medicina Geral e Familiar; 33-9
2182-5181
2182-5173
10.32385/rpmgf.v34i1
reponame:Repositórios Científicos de Acesso Aberto de Portugal (RCAAP)
instname:FCCN, serviços digitais da FCT – Fundação para a Ciência e a Tecnologia
instacron:RCAAP
instname_str FCCN, serviços digitais da FCT – Fundação para a Ciência e a Tecnologia
instacron_str RCAAP
institution RCAAP
reponame_str Repositórios Científicos de Acesso Aberto de Portugal (RCAAP)
collection Repositórios Científicos de Acesso Aberto de Portugal (RCAAP)
repository.name.fl_str_mv Repositórios Científicos de Acesso Aberto de Portugal (RCAAP) - FCCN, serviços digitais da FCT – Fundação para a Ciência e a Tecnologia
repository.mail.fl_str_mv info@rcaap.pt
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