Abstract

SANTANA PORBEN, S.. Records and documentation system: Its location within a program of alimentary, nutritional and metabolic intervention. Nutr. Hosp. [online]. 2005, vol.20, n.5, pp.331-342. ISSN 1699-5198.

Objectives: To present the Records and Documentation System of the Metabolic, Nutrient and Feeding Intervention Program (PRINUMA), as conducted by the Nutritional Support Group (GAN) of the "Hermanos Ameijeiras" Hospital (Havana City, Cuba). Background: Every action conducted upon the patient must have a document backup. Likewise, this action should be exhaustively described in a Standerdized Operating Procedure (SPO). The Records and Documentation System must provide with: 1) Primmary records for registering the actions conducted upon the patients, 2) SOP manuals gathering the actions prescribed in the PRINUMA for the recognition, treatment and prevention of hospital malnutrition (HM), and 3) Computerized clinical registries for storing, manipulation and dissemination of data collected by the GAN during its local operation. Methods: The ISO 9001-9003 standard was adopted for describing the actions prescribed by the PRINUMA into the corresponding SOPs. Access 7.0 for Windows (Microsoft, USA) was used for the programming and operation of the GAN'S computerized Clinical Registry. Three phases were defined for the implementation of this System: I: start-up (minimal); II: extended; III: total (global). Results: System implementation is in phase II. A Procedure Manual has been written with clinical, anthropo-metric, dietetic, dietotherapeutical and analytical actions prescribed by the PRINUMA for the treatment of HM. There is a second Manual reuniting the actions fostered by the PRINUMA's Quality Control & Assurance and the Records & Documentations Systems. GAN also has a Nutritional Clinical History and a computerized Clinical Registryt serving as digital counterpart of the former. The Registry stores data of varying type collected from over 1.800 patients attended in the 8 years of the GAN existence. Conclusions: The implementation of the PRINUMA's Records and Documentation System has allowed the elaboration of judgements about the utility and safety of the intervention measures installed in the institution by the GAN. Likewise, the System has supported the research activity of the Group, and has been particularly useful in the conduction of continuous education activities within the institution.

Keywords : Registry; Record; Documentation; Databases; Intervention Programs; Standardized Operating Procedure; Nutritional Support Group.

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