Conciliation of health information: activities performed in a municipal urgency and emergency hospital

Abstract

Objective: To present the methodology developed by the Pharmacy Service to collect health information in computerized databases in a trauma referral hospital. Methods: The study followed the exploratory descriptive model, between January and June 2022. The pharmacy team developed an instrument for selecting and analyzing patient data from the hospital’s computerized system and e-SUS, DIS (Dispensing of Medicines) and Gercon (Management of Appointments). By comparing the data verified in the external systems, the relevant information was selected and recorded in the medical record. Interventions were evaluated for acceptance or not by the care team. Results: Information from 1712 hospitalized users was screened, of which (63.6%) patients were male and 62.5% declared to be residents of Porto Alegre. The health information of 829 patients was verified and of these, 128 (15.4%) had some information considered relevant to the user’s hospitalization. Of the 106 reconciliations carried out, 103 originated in the screening of patient information and three occurred at the request of the care team. This practice collaborates with the reconciliation of health information such as medication use, comorbidities, health history and exams, many of which were created for care during hospitalization. Conclusions: The reconciliation of health information qualifies care, in addition to integrating the pharmaceutical professional into the multidisciplinary team. The improvement and integration of records in health-related databases can result in more safety in the care of hospitalized patients.