A gestão documental de prontuário do paciente em saúde pública municipal em Aracaju : da situação real para a ideal e sua inovação

Abstract

The constant advancement of information technologies has significantly transformed life in society, causing changes in the management structure of innumerable sectors of administration, such as health, where the use of information is the main tool in patient care, carried out through the use of medical records, document used for medical follow-up. However, over the years, the use of this in paper support, made it difficult to assist the user, since it no longer presents great functionality, being exposed to serious damages. Therefore, it is evident the importance of the transition to electronic support, where they will be managed in an effective and intelligent way, through functional management of information management. In order to analyze the data, the content analysis method was used, which demonstrated a great lack in the documentary management of US 'Celso Daniel', where the patient’s record are archived incorrectly, evidencing also that the accomplishment of the information management processes can contribute to improvement in the quality of care. As products generated by the research, the actual process, the ideal and the innovation were mapped, demonstrating that the information contained in paper records can be preserved and incorporated into electronic records by simple measures, with existing equipment and available programs. The entire process was described and explained through a Management and Good Practices Manual, with clear language and perfectly applied by the Health Units team.As final considerations, the research demonstrated that the application of information management depends directly on the initiative of its managers, through the realization of skills that lead the professionals of the institution to correct document management, qualifying the service performed in the unit.