Propuesta de un modelo de historia clínica digitalizada para el seguimiento de pacientes con nefritis lúpica
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Fecha
2020
Autores
Ortega Lasso, Maximiliano
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Ediciones Universidad Simón Bolívar
Facultad de Ciencias de la Salud
Facultad de Ciencias de la Salud
Resumen
Un adecuado manejo de la historia clínica impacta al paciente, el cual requiere de atención de calidad, eficiente, de una manera ágil y oportuna, asimismo, genera impacto en el profesional médico, por cuanto, la HC como herramienta tecnológica optimiza su quehacer, facilitando la toma de decisiones; lográndose, además, la uniformidad de los registros, posibilitando la organización de toda la información referente al paciente. El objetivo del presente trabajo fue diseñar un modelo de historia clínica digitalizada para el seguimiento de pacientes con nefritis lúpica en la Clínica de la Costa del Departamento Atlántico, Barranquilla, para lo cual se realizó un estudio cuantitativo, implementándose un modelo de historia clínica electrónica dirigido a la atención de pacientes con diagnóstico de NL, tras lo cual se encuesto a cada uno de los digitadores con respecto a facilidad y utilidad de la plataforma y se hizo un análisis preliminar de los datos obtenidos, encontrándose que 83% de los médicos diligenciaron la HC, 100% la consideraron de fácil acceso, 40% refieren que nunca se bloquea, 100% refieren que el contenido es claro y comprensible y no realizaron sugerencias. Con respecto a la información obtenida a través de la historia clínica se encontró que 89% eran mujeres, la mediana de edad fue de 31 años, 66% tuvieron anti-DNA positivo, 75% presentaron C3 bajo y 72% C4 bajo, 24% NL clase IV y 89% recibían tratamiento. Finalmente se concluyó que los profesionales de la salud a diario se encuentran en el proceso de cambios tecnológicos incluyendo a la historia clínica la cual hace parte de su actividad profesional diaria, hoy en día se han incluido las TICS en la vida cotidiana con el fin de reforzar, optimizar y facilitar las actividades conllevando a mejorías en cuanto a la calidad de atención, disposición y uso de la información.
Proper management of the medical history impacts the patient, which requires quality, efficient care, in an agile and timely manner, and also generates an impact on the medical professional, since HC as a technological tool optimizes their work, facilitating decision making; Achieving, in addition, the uniformity of the records, allowing the organization of all information regarding the patient. The objective of this work was to design a digitized medical record model for the follow-up of patients with lupus nephritis at the Clinic of the Coast of the Atlantic Department, Barranquilla, for which a quantitative study was carried out, implementing a directed electronic clinical record model to the care of patients with a diagnosis of NL, after which each of the digitizers was surveyed regarding the ease and usefulness of the platform and a preliminary analysis was made of the data obtained, finding that 83% of the doctors completed the HC, 100% considered it to be easily accessible, 40% reported that it was never blocked, 100% reported that the content was clear and understandable and did not make any suggestions. Regarding the information obtained through the clinical history, it was found that 89% were women, the median age was 31 years, 66% had positive anti-DNA, 75% had low C3 and 72% low C4, 24% NL class IV and 89% received treatment. Finally, it was concluded that health professionals are in the process of technological changes daily, including the medical history, which is part of their daily professional activity. Today, ICTs have been included in everyday life to reinforce, optimize, and facilitate activities leading to improvements in the quality of care, disposition and use of information.
Proper management of the medical history impacts the patient, which requires quality, efficient care, in an agile and timely manner, and also generates an impact on the medical professional, since HC as a technological tool optimizes their work, facilitating decision making; Achieving, in addition, the uniformity of the records, allowing the organization of all information regarding the patient. The objective of this work was to design a digitized medical record model for the follow-up of patients with lupus nephritis at the Clinic of the Coast of the Atlantic Department, Barranquilla, for which a quantitative study was carried out, implementing a directed electronic clinical record model to the care of patients with a diagnosis of NL, after which each of the digitizers was surveyed regarding the ease and usefulness of the platform and a preliminary analysis was made of the data obtained, finding that 83% of the doctors completed the HC, 100% considered it to be easily accessible, 40% reported that it was never blocked, 100% reported that the content was clear and understandable and did not make any suggestions. Regarding the information obtained through the clinical history, it was found that 89% were women, the median age was 31 years, 66% had positive anti-DNA, 75% had low C3 and 72% low C4, 24% NL class IV and 89% received treatment. Finally, it was concluded that health professionals are in the process of technological changes daily, including the medical history, which is part of their daily professional activity. Today, ICTs have been included in everyday life to reinforce, optimize, and facilitate activities leading to improvements in the quality of care, disposition and use of information.
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Palabras clave
Historia clínica electrónica, CRF, Nefritis lúpica, Tecnologías de Información y Comunicación, Electronic medical record, Lupus nephritis, Information and Communication technologies