Einstein (São Paulo) (Mar 2008)
The use of an electronic medical system in a pediatric emergency department with a clinical score triage system
Abstract
Objective: To describe the implementation of an electronic medicalhealth care system in a tertiary pediatric emergency departmentby means of reporting some care indicators before and afterimplementation. Methods: A descriptive, retrospective studydescribing the implementation strategy of an electronic medical record system was conducted at the Emergency Department of the Instituto da Criança of the Faculdade de Medicina da Universidade de São Paulo. The system was assessed during the period between January 1st, 2005 and June 30th, 2006, after the implementation of the electronic medical record system, and the indicators took into consideration were number of patients seen (89,429) and distribution according to the clinical score, hospital stay, amount of mislaid or lost medical records, number of drop outs, waiting time for medical consultation and percentage of patients discharged home according to the score. Health care indicators such as waiting time, percentage of mislaid or lost medical records and patient drops out were compared between March 2005 and March 2000 – the period prior to implementation of the electronic medical record. Results: During the period prior to the implementation of the electronic medical record, the average time spent at the hospital was four hours and seven minutes, 5.1% of medical records were mislaid or lost, and 4.8% of patients seen were admitted to the hospital. Duringthe post-implementation period, the average time spent at hospital was two hours and three minutes, no medical records were mislaid or lost, and 6% of patients seen were admitted to the hospital. Conclusions: The use of an electronic medical record improved patient flow, medical records were more complete and increased team satisfaction.
