Resumo

CRUZ GIL, María del Carmen. Medical record digitalization: analysis of a real life project involving the Extremadura Health Service in Spain. Rev. cuba. inf. cienc. salud [online]. 2020, vol.31, n.3  Epub 30-Out-2020. ISSN 2307-2113.

A health information management case study is presented in a which scientific literature review revealed that information technologies have been incorporated into Spanish public health in an uneven, irregular manner. To corroborate this fact we set ourselves the objective of analyzing the way in which a medical record digitalization project is conducted, which led to the following research questions: How is health information managed? How is a medical record digitalization project conducted in a real life context? What is the background of professionals involved in the process and what is the role of documentalists? Besides examination of the scientific literature, a naturalist qualitative analysis was performed in which the results of the study were presented, based on equipment provision, advisory service, document management and archiving, and the professional profile established for the conduct of a medical record digitalization project. It is concluded that information management does not meet the needs of the health personnel, that a documented procedure is not available for medical record digitalization, and that participation of health professionals and documentalists is not requested, despite the scientific literature highlighting the invaluable participation of these professionals.

Palavras-chave : Medical records; digitalization; Extremadura Health Service; information; clinical documentation.

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