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CC BY 4.0 · Rev Bras Ginecol Obstet 2016; 38(01): 009-019
DOI: 10.1055/s-0035-1570109
Original Article

Uso do prontuário eletrônico na assistência pré-natal às portadoras de diabetes na gestação

Electronic Medical Record for Prenatal Care of Diabetic Women
Alina Coutinho Rodrigues Feitosa
1   Escola Bahiana de Medicina e Saúde Pública, Salvador, BA, Brasil
2   Serviço de Endocrinologia da Maternidade Prof José Maria de Magalhães Netto, Salvador, BA, Brasil
,
Amado Nizarala de Ávila
1   Escola Bahiana de Medicina e Saúde Pública, Salvador, BA, Brasil
3   Residência de Obstetrícia da Maternidade Prof José Maria de Magalhães Netto, Salvador, BA, Brasil
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Resumo

Objetivo Apresentar e validar um registro eletrônico de saúde (RES) multifuncional para atendimento ambulatorial a portadoras de endocrinopatias na gestação e comparar a taxa de preenchimento de informações de saúde com o prontuário convencional.

Métodos Desenvolvemos um RES denominado Ambulatório de Endocrinopatias na Gestação eletrônico (AMBEG) para registro sistematizado das informações de saúde. O AMBEG foi utilizado para atendimento obstétrico e endocrinológico de gestantes acompanhadas no ambulatório de endocrinopatias na gestação na maternidade referência em gestação de alto risco na Bahia, no período de janeiro de 2010 a dezembro de 2013. Aleatoriamente foram selecionadas 100 pacientes atendidas com o AMBEG e 100 pacientes atendidas com prontuário convencional com registro em papel e comparou-se a taxa de preenchimento de informações clínicas.

Resultados Foram realizados 1461 atendimentos com o AMBEG: 253, 963 e 245 respectivamente, admissões, consultas de seguimento e puerpério. Eram portadoras de diabetes 77,2% e sendo 60,1% portadoras de diabetes pré-gestacional. O AMBEG substituiu, satisfatoriamente, o prontuário convencional. O percentual de informações clínicas registradas em ambos os prontuários foi significativamente maior no AMBEG: queixas clínicas (100 versus 87%, p < 0,01), altura uterina (89 versus 75%, p = 0,01), ganho de peso total (91 versus 40%, p < 0,01) e dados específicos sobre o diabetes (dieta, esquema de insulina, controle glicêmico e manejo de hipoglicemias) revelando diferença significativa (p < 0,01). A possibilidade de exportar dados clínicos para planilhas facilitou e agilizou a análise estatística de dados.

Conclusões O AMBEG é uma ferramenta útil no atendimento clínico a mulheres portadoras de endocrinopatias na gestação. A taxa de preenchimento de informações clínicas foi superior à do prontuário convencional.

Abstract

Objective To present and validate a multifunctional electronic medical record (EMR) for outpatient care to women with endocrine disorders in pregnancy and to compare health information data fill rate to conventional medical records.

Methods We developed an EMR named Ambulatory of Endocrine Diseases in Pregnancy (AMBEG) for systematic registration of health information The AMBEG was used for obstetric and endocrine care in a sample of pregnant women admitted to the maternity reference in high-risk pregnancies in Bahia from January 2010 to December 2013. We randomly selected 100 patients accompanied with AMBEG and 100 patients monitored with conventional consultation and compared the health information data fill rate of the electronic consultation to that performed using conventional medical records.

Results 1461 consultations were held, of which 253, 963 and 245 were first, follow-up and puerperium consultations, respectively. Most patients were pregnant women with diabetes (77.2%) and 60.1% were women with pre-gestational diabetes. The AMBEG satisfactorily replaced the conventional medical record. The percentage of registered information was significantly higher in the AMBEG: clinical symptoms (87% versus 100, p < 0.01), uterine height (89 versus 75%, p = 0.01), total weight gain (91 versus 40%, p < 0.01) and specific diabetes data (diet, insulin regimen, glycemic control and management of hypoglycemia) revealed a significant difference (p < 0.01). The ability to export data to worksheets greatly facilitated and accelerated the statistical analysis of the data.

Conclusions AMBEG is a useful tool in clinical care for women with endocrine diseases during pregnancy. The fill rate of clinical information was superior to that registered in conventional medical records.

Palavras-Chave

diabetes mellitus - gravidez em diabéticas - diabetes gestacional - sistemas computadorizados de registros médicos - doenças do sistema endócrino

Keywords

diabetes mellitus - pregnancy in diabetics - gestational diabetes - medical records systems - computerized - endocrine system diseases


Publication History

Received: 31 July 2015

Accepted: 14 October 2015

Publication Date:
30 December 2015 (online)

© 2016. Federação Brasileira de Ginecologia e Obstetrícia. This is an open access article published by Thieme under the terms of the Creative Commons Attribution License, permitting unrestricted use, distribution, and reproduction so long as the original work is properly cited. (https://creativecommons.org/licenses/by/4.0/)

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