Audit of electronic medical records and satisfaction of emergency room medical staff of the Dr. Juan Vega Méndez Policlinic, Panamá Oeste.

Abstract

The general objective of this research is based on Analyzing the Audit of electronic medical records and its relationship with the satisfaction of the medical staff in the emergency room of the Dr. Juan Vega Méndez Polyclinic, Panama. The research subscribes to the positivist paradigm, quantitative approach, non-experimental design. A total of twelve (12) Staff Doctors plus five (05) Support Doctors work in the emergency room of the Polyclinic under study (these only work extraordinary shifts on weekends and holidays). The sample surveyed was considered census, and amounts to a total of seventeen (17) doctors. A total of 333 medical records were also selected, from the 2432 medical records recorded in the month of March of the year, in the emergency room of the Polyclinic under study. The survey technique was applied through the questionnaire and for the purposes of its analysis, descriptive statistics were used. In general terms, the quality of the clinical history recording is considered good, however, it is considered that there are elements or factors that must be improved to achieve higher and better levels of excellence in the audit of electronic medical records and satisfaction of medical staff. In conclusion, it is stated that the main factors to improve are based on the adequate record of: appropriate recognition of the medicine prescription: portions, level of concentration, route of administration, periodicity, hygienic - dietary guidelines, preventions; record of progress notes, therapeutic plan record.