Evolução farmacêutica: implementação em um hospital universitário com a utilização de prontuário eletrônico
DOI:
https://doi.org/10.34019/1982-8047.2024.v50.44192Keywords:
Hospital Pharmacy Service. Pharmacist. Electronic Health Records. Clinical Pharmacy Information System. Pediatrics.Abstract
Objective: The study aimed to build semi-structured models to implement the pharmaceutical evolution in the electronic health records in the pediatrics unit of the University Hospital of the Federal University of Juiz de Fora - Minas Gerais. Methods: The descriptive cross-sectional study was conducted with individuals who were admitted to the non-COVID-19 pediatrics unit from December 01, 2021 to January 31, 2022, and had the pharmacist's clinical activities recorded in their electronic health record. Information was collected from users through the Pharmaceutical History Taking and from the history taking of other professionals, besides the evaluation of prescriptions and recording of interventions suggested by the pharmacist according to the identification of inconsistencies regarding dose, dilutions/diluents, drug interactions, occurrence of adverse reactions, therapeutic duplicity, Y- incompatibilities, and health education. Results: Fourteen semi-structured models based on the SOAP method (Subjective; Objective; Assessment; Plan) were created to implement the pharmaceutical evolution with record standardization. During the study period there were 66 hospitalizations. Of these, 45 were eligible and recorded in the electronic document of the pharmaceutical history taking and the result of the assessment of the daily prescriptions, with or without pharmaceutical interventions. Conclusion: The study showed that the electronic health record provides better continuity of care by the pharmacy team within the pediatric sector and broad access to information, in addition to enriching communication and valuing the service of the clinical pharmacist.
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