Resumo

PEREZ-MARTI, Montserrat; CASADO MARIN, Lina Cristina  e  ROMANI ALFONSO, José Oriol. A situational study of electronic records in an internal medicine unit: barriers and opportunities. Enferm. glob. [online]. 2018, vol.17, n.51, pp.180-199.  Epub 01-Jul-2018. ISSN 1695-6141.  https://dx.doi.org/10.6018/eglobal.17.3.284211.

The objective of this study was to identify the resources, workflows and perception of nurses of internal medicine unit, related to electronic records in order to determine if the implementation of tablets in hospital units could cover the nurses’ needs more satisfactorily.

A descriptive, cross-sectional study with non-probability sampling was carried out during July and August of 2016. The study involved 31 observations of 18 nurses, with 392 patients admitted. The variables were: shift, working methodology, "round" time, time taken to write up data, total time, number of patients admitted and time spent per patient. Each nurse was asked how they worked and why.

The average total time was 59,16 min (DT:16,6), and 12.65 (DT:1,11) patients admitted. Time spent per patient was 4,65 min (DT:1,15) and was lower during the afternoon shift [M:4,14; [DT: 0.84] than during the night shift [M: 5.47; DT: 1,12]. The night shift always used the same method of work, whereas different systems were used during the afternoon. The nurses expressed the need for a lightweight record system that would enable them to record information in real time near the patient without having to go elsewhere, and which would make it easy to consult and exchange information.

The two working methods used in the observation unit do not satisfy the needs of nurses, are slow and cumbersome and make it difficult for nurses to access and record information. The adoption of tablets could reduce these problems and meet nurses’ expectations and thus opens a new line of research.

Palavras-chave : Electronic Health Records; Nursing; Computers Handheld; Equipment and Supplies; Internal medicine.

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