PRONTUÁRIO ELETRÔNICO DO CIDADÃO NA GESTÃO DO CUIDADO DE PESSOAS COM DIABETES MELLITUS TIPO 2

Abstract

This study aims to analyze the use of Electronic Health Record (EHR) and their completeness in the monitoring of people with type 2 diabetes mellitus (T2DM) in Primary Health Care (PHC). This is a quantitative and descriptive study using data from the medical records of 537 patients with T2DM (age ≥ 18 years) at a Basic Health Unit in the Midwest, of these, 404 were eligible to participate in the research. Exclusion criteria included: death; unavailability of data for risk stratification and absence of consultations; laboratory tests without a date from 2023; diagnosis of type 1 diabetes mellitus; resolved T2DM and/or undiagnosed patients; and age <18 years. Data collection took place between January and July 2024, based on information from January to December 2023. Data collection included identification, consultations, examinations, foot assessments, and multidisciplinary referrals within the last year. The results revealed that, of the 404 eligible medical records, 61.2% were women and 66.2% were elderly. There was a lack of records on education (64.3%), occupation (98.0%), and marital status (97.5%). Participation in the HIPERDIA program was absent in 52.0% of the records, as was the failure to perform a diabetic foot exam in 90.1% of cases. Records of multidisciplinary care records were scarce: 85.9% did not have a dentist, 98% did not have a nutritionist, and 92.4% did not have an ophthalmologist. The results highlighted that the effectiveness of the EHR in the management of T2DM depends on the quality and comprehensiveness of the records. The findings emphasize the need for continuing education for healthcare teams on the use of the EHR as a clinical and epidemiological management tool, and the encouragement of adherence to management manuals and clinical protocols. This demonstrates that complete record keeping is essential for generating indicators that guide improvements in the quality of care and the correct risk stratification to define more effective care pathways.

Descriptors: unified health system; primary health care; diabetes mellitus, type 2; electronic health records; health information system.