标题：Buscando um registro mais integral do cuidado à saúde: desenvolvimento, aplicação e avaliação de um novo instrumento de registro da consulta ambulatorial
期刊名称：Revista Brasileira de Medicina de Família e Comunidade
印刷版ISSN：1809-5909
电子版ISSN：2179-7994
出版年度：2005
卷号：1
期号：3
页码：81-91
DOI：10.5712/rbmfc1(3)13
语种：Portuguese
出版社：Sociedade Brasileira de Medicina de Família e Comunidade (SBMFC)
摘要：The medical record is important for health care since it allows, through the analysis of data collected in several contacts between patients and health units, to appreciate and understand the disease and health care processes. This comprehension will be the more complete, the more the medical record accounts for the patients way of living, health-disease processes, investigations and therapeutic procedures, clinical evolution and possible difficulties to follow medical advice that is, the way health care was/is delivered by different professionals in several sectors. In this sense, the service and its record as well must focus on the individual, the person as a whole, living and becoming ill, and not only on his diseases and morbidities. Based on this premise, this study aimed to develop, apply and assess a new tool for outpatient records at the Integral Ambulatory Care (AMI) at Pedro Ernesto University.
关键词：Registros médicos;Cuidados integrais de saúde;Sistemas de Informação;Assistência ambulatorial;Assistência Integral à Saúde
其他关键词：Medical records;Ambulatory care;Information System;Comprehensive Health Care
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