Sistema de informação em crianças obesas na primeira infância

Abstract

Introduction. The Electronic Health Record is defined as a computerized clinical and administrative record of the patient's health and illness within a system used to support users, providing access to a complete set of correct data, alerts and decision support systems. The implementation of well-structured medical records leads to an improvement in care at the most diverse levels, to high quality individualized care, thus providing valuable data to health managers. In effect, the development of a technological database, supported by physical records, as well as the implementation of the Electronic Health Record, can produce beneficial effects to the treatments carried out at the child obesity clinic of IPREDE. Objective. Create a technological database that allows for better data analysis, and better knowledge of the profiles of the patients’ seen at the child obesity outpatient clinic of IPREDE, and to later propose the development of electronic medical records. Methodology. At a different moment, a technological database was implemented regarding the population assisted in the obesity outpatient clinic of IPREDE and, based on such data, diagnostic and descriptive evaluations were made. Given this analysis, the implementation of an electronic medical record was suggested. Results. The database was created in February 2020. In analyzing the profile of the assisted population, it was observed that of the 172 medical records, 51.7% of the children were male and the majority, 69.7% were preschoolers. 70% of the mothers were overweight. In outpatient care, it was demonstrated that 62.5% of the children did not have routine weight care and 73.8% did not receive nutritional guidance during medical appointments. Of those who took laboratory tests (> 2 years), 24,07% presented high total cholesterol, 31.3% presentend high triglycerides, 71.4% presented low HDL cholesterol, 13,2% presented high LDL cholesterol and 81.8% were diagnosed with dyslipidemia. Conclusion. The implementation of the information system brought agility and the possibility of systematic analysis of children’s nutritional health. A worrisome situation was observed, due to the “obesogenic” habits of the assisted population and to the obesity related results found in the laboratorial tests. The study highlighted the need to improve medical records’ filling and presented the need to implement electronic medical records as an opportunity to be more effective in collecting data and monitoring appointments, aiming at a better structuring of the service.