Prontuário eletrônico do cidadão e gerência do cuidado de enfermagem na Atenção Básica: um estudo de caso

Abstract

The use of information technology, especially the electronic medical record, is growing in the health area. The use of the electronic medical record aims to contribute by improving the quality and efficiency of health care through the management of information recorded by health professionals. The objective was to know the repercussions of the implantation of the Electronic Citizen Record (PEC) for the management of nursing care at Juiz de Fora - MG. Method: case study with exploratory research, with qualitative approach, developed in two phases. Through documentary research at the Health Department, made between September 2018 and February 2019, were obtained the characterization of PEC implementation scenario in the city and the identification of the nurses that satisfy the inclusion criteria for the interviews. 17 nurses from the Basic Health Units (UBS) who used the PEC were interviewed from October 2018 to February 2019. For data collection, all interview were recorded and guided by semi-structured script. The analysis of the content of the interviews was operationalized through the IRaMuTeQ alpha 2 software. The collected data with the two phases of the research were transcribed into the software Word for Windows and analyzed separately and subsequently the products of the analyzes were articulated / related during the results. The study was approved by the Committee of Ethics in Research, in accordance with the Opinion of No. 2.876.225. As results the scenario of implantation of the PEC in the city of Juiz de Fora was described and it was verified that the implantation of the PEC was completed in 28 UBS. From the analysis of the content of the interviews by IRaMuTeQ, 5 classes emerged, which served as a basis for forming 2 categories according to Minayo operational proposal. In these classes emerged the contributions of the use of the PEC for the information management and for the management of the nursing care. The nurses acknowledge that the PEC contributes to the management of nursing care, but they emphasize that the work overload and the lack of awareness of the other team members interfere in the consolidation of this process. In addition, it was noticed that nurses underutilized the PEC when reporting the use of information from the system to account for the production of professionals. The nurses highlighted the facilities / potentialities and difficulties in using the PEC. And they emphasized the need for training and the creation of spaces for discussion. In addition, the nurses highlighted the reflexes of the use of the PEC for the users. It was observed that PEC is recognized as a qualifying instrument of health care, as it contributes to the management of nursing care in AB. However, for this tool to be effectively used it is necessary to minimize the weaknesses and deficiencies presented by the participants. Further studies may expand and deepen the use of the PEC for health planning, with the involvement of other AB professionals.