A Single Process

Abstract

A correct and complete documentation of patient
data is essential for good medical practice. The best
use of health resources, an adequate perception of
the clinical situation and patient satisfaction can only
be achieved through information exchange between
the health professionals responsible for patient care.
Traditionally there is a separation between medical records in the Health Center and in the Hospital. In
the more developed countries, as far as health care
organization is concerned, efforts are progressing
to link information in the so-called Integrated
Clinical Patient Notes. In direct contrast, in some
central Portuguese Hospitals, we are still at the stage
of linking information pertaining to the several
Hospital Admissions and Consultations of a
particular patient in the same Hospital. Examples
of daily problems related to patient clinical notes in
the Emergency Service and at the time of Hospital
Admission are reported and suggestions are made for their resolution