In the General Hospital of Montemorelos, of Health Services of Nuevo Leon, OPD, the implementation of an electronic clinical record system has been carried out since 2015, with the intention of improving the quality of patient care by having easy access to medical notes by health professionals, better control of medicines and supplies and therefore a more efficient distribution and allocation of resources, as well as having more reliable statistics that allow for better decisions.

Initially, it was expected to have resistance from the personnel to the changes, and indeed there was resistance on the part of some doctors. However, most of them were very willing to adopt technological tools. In addition, as the use of the system became a daily routine, the size of our database has increased considerably, which is why we have more medical information that is useful to the staff in making decisions about the treatment of each patient.

We also expected to have more reliable statistics, and although we began to extract information through the system, we found the need to improve the quality of the records in it; and it is one of the tasks we have today. Regarding the control of medicines and supplies, the system for dispensing medicines is currently in operation, and we are in the planning to phase in the control of dressings, bandages and other materials. It must be kept in mind that the process of implementing a system is continuous, which includes updating equipment and supervising the capture of information; that is precisely what must still be improved. In addition, involving hospital authorities was essential for success.

Author:
Dr. Alejandro Bahena Pérez
Deputy Director General Hospital of Montemorelos
Health Services of Nuevo León, O.P.D.

Category: Post-action reviews

Title of the project: Implementation of an electronic clinical record system in a Rural Hospital in Mexico

Lead Institution: Health Services of Nuevo León, O.P.D.

Country: Mexico

City: Montemorelos, Nuevo León

Implementation Period: 2015 to date

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