AGILECLINIC: sistema de prontuário eletrônico do paciente baseado nas especificidades da terapia ocupacional usando a CIF como modelo de classificação

Abstract

Recording patient information in medical records is a mandatory practice for healthcare professionals. The National Council of Physiotherapy and Occupational Therapy established the minimum composition and the obligation of an Occupational Therapeutic record through resolution COFFITO-415. This determination by the council is necessary considering that the information recorded in the medical records feeds into several processes within the structure of health services provision. Despite the mandatory and outstanding importance, the few national studies that have focused on themes involving the practice of recording in medical records have identied diculties with impacts in several dimensions, especially in the quality of the documents produced. The present study analyzed the perception of 502 Occupational Therapists who participated in the survey by answering an online questionnaire with questions about the use of electronic patient record systems. As a result, functional gaps were identied in the existing tools that somehow interfere with the quality of the documents produced and the work processes related to this practice. Thinking aboutlling these gaps, the objective of this project was to develop an electronic patient record system, called Agileclinic, considering the specicities of occupational therapy and the non-existent requirements in current platforms, according to the report of the professionals in the area. In addition, the project adopted the International Classication of Functioning, Disability and Health (ICF) as the base model to classify the patient’s health condition. After implementing the platform, seven Occupational Therapists, with at least 5 years of experience and working in dierent areas, got to know the features and evaluated the system. Among the various points evaluated, the following stand out: i) the perception of the availability of automated reports and graphs, which had 100% of the evaluations as good and very good. ii) Attribution of an overall grade equal to 10 for the platform by 71.4% of the study participants.