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.
Downloads
References
Bonnici A, Bussières J-F, Bornstein C, Doucette D, Hall K, Jones R et al. Hospital Pharmacy in Canada 2013/2014 Report [Internet]. Canada Editorial Board. 2013 [cited 2024 Jan 11]. Available at: https://www.cshp.ca/docs/pdfs/FULL-2015.pdf.
Hammond RW, Boyce B, Briceland L, Canaday B, Carr-Lopez SM, Eggleston ST et al. ASHP guidelines on documenting pharmaceutical care in patient medical records. American Journal of Health-System Pharmacy. 2003; 60(7):705-7.
Néri EDR, Vasconcelos HBS, Romeu GA, Fonteles MMF. Do Brazilian hospital pharmacists record, document, archive and disseminate their clinical practice? Braz J Pharm Sci. 2019; 55.
Pullinger W, Franklin BD. Pharmacists’ documentation in patients’ hospital health records: issues and educational implications. Int J Pharm Pract. 2010; 18(2):108-15.
Conselho Federal de Medicina (BR). Resolução n° 1638, de 10 de julho de 2002 [Internet]. Define prontuário médico e torna obrigatória a criação da Comissão de Revisão de Prontuários nas instituições de saúde. CFM; 2002 [cited 2024 Jan 11]. Available at: https://sistemas.cfm.org.br/normas/arquivos/resolucoes/BR/2002/1638_2002.pdf.
Conselho Federal de Farmácia (BR). Resolução n° 555, de 30 de novembro de 2011 [Internet]. Regulamenta o registro, a guarda e o manuseio de informações resultantes da prática da assistência farmacêutica nos serviços de saúde. CFF; 2011 [cited 2024 Jan 11]. Available at: https://www.cff.org.br/userfiles/file/resolucoes/555.pdf.
Conselho Federal de Medicina (BR). Resolução CFM n° 1.638, de 10 de julho de 2002 [Internet]. Define prontuário médico e torna obrigatória a criação da Comissão de Revisão de Prontuários nas instituições de saúde. CFM; 2002 [cited 2024Jan11]. Availableat:https://www.saude.sp.gov.br/resources/ses/perfil/profissional-da-saude/homepage/cada/prontuario_de_paciente.pdf.
Conselho Federal de Farmácia (BR). Resolução n° 585, de 29 de agosto de 2013 [Internet]. Regulamenta as atribuições clínicas do farmacêutico e dá outras providências CFF; 2013 [cited 2024 Jan 11]. Available from: https://www.cff.org.br/userfiles/file/resolucoes/585.pdf
Shymenes DC J, Mariz Batista A. Desenvolvimento de formulário para registro do processo de cuidado farmacêutico no contexto de um hospital materno-infantil do seridó potiguar. Infarma Ciências Farmacêuticas. 2021; 33(3):283. doi: 10.14450/2318-9312.v33.e3.a2021.pp283-290
Simenson ST, McGivney MS. Medication therapy management services: creating a patient care process for MTM in your practice: modulo 4 [Internet]. American Pharmacists Association; 2007 [cited 2024 Jan 11]. Available at: https://aphanet.pharmacist.com/sites/default/files/files/mtm_creating_patient_care_process.pdf.
Taylor G, Leversha A, Archer C, Boland C, Dooley M, Fowler P et al. Clinical pharmacy COSP- standards of practice for clinical pharmacy services chapter 13 (S42-S46). Journal of Pharmacy Practice and Research. 2013; 43(S2). Available at: https://research.monash.edu/en/publications/overview-standards-of-practice-for-clinical-pharmacy-services.
Amorim SA, Lima AMA, Neto JMDA, Andrade CC, Sidney KMM. Construção de um modelo de evolução farmacêutica em prontuário médico. Infarma Ciências Farmacêuticas. 2019; 31(2):129.
Zierler-Brown S, Brown TR, Chen D, Blackburn RW. Clinical documentation for patient care: models, concepts, and liability considerations for pharmacists. Am J Health Syst Pharm. 2007; 64(17):1851-8. doi: 10.2146/ajhp060682
Lima ÉD, Silva RG, Ricieri MC, Blatt C. Farmácia clínica em ambiente hospitalar: enfoque no registro das atividades. Rev Bras Farm Hosp Serv Saúde. 2017; 8(4):18-24.
Freitas GR, Pinto SR, Dos M, Luna-Leite A, Castro MS et al. Principais dificuldades enfrentadas por farmacêuticos para exercerem suas atribuições clínicas no Brasil. Rev Bras Farm Hosp Serv Saúde. 2016; 7(3):35-41.
Vedel I, Lapointe L, Lussier MT, Richard C, Goudreau J, Lalonde L, Turcotte A. Healthcare professionals’ adoption and use of a clinical information system (CIS) in primary care: insights from the Da Vinci study. Int J Med Inform. 2012; 81(2):73-87.
Émilin DL, Blatt CR, Aquino Caregnato RC. Registro das atividades clínicas do farmacêutico hospitalar: uma revisão integrativa. Revista Contexto & Saúde. 2020; 20(38):101-12.
Mackinnon III GE, Mackinnon NJ. Documentation of pharmacy services: chapter 7. In: DiPiro JT, Talbert RL, Yee GC, Matzke GR, Wells BG, Posey LM. Pharmacotherapy: a pathophysiologic approach. [S.l.]: McGraw-Hill; 2011. p. 47-56.
Krauter Canêo P, Marcelo Rondina J. Prontuário eletrônico do paciente: conhecendo as experiências de sua implantação. J Saúde Informa. 2014; 6(2): 67-71.
Prebianchi HB. Comunicação da equipe interdisciplinar na assistência aos pacientes cirúrgicos. Revista Temas em Educação e Saúde. 2017; 13(1):164-78.
Downloads
Published
How to Cite
Issue
Section
License
Copyright (c) 2024 Marianne Teixeira Trindade, Milene Machado Minateli
This work is licensed under a Creative Commons Attribution 4.0 International License.
Cessão de Primeira Publicação à HU Revista
Os autores mantém todos os direitos autorais sobre a publicação, sem restrições, e concedem à HU Revista o direito de primeira publicação, com o trabalho licenciado sob a Licença Creative Commons Attribution que permite o compartilhamento irrestrito do trabalho, com reconhecimento da autoria e crédito pela citação de publicação inicial nesta revista, referenciando inclusive seu DOI.
