What is Paper-Based Patient Record

Medical information produced in hospitals is, simultaneously, used (1) to support health care provided to patients, (2) in research work performed by internal and external health professionals, and (3) as legal proof with various objectives. The co-existence of electronic and paper health information, the integration constraints of the various computer applications, and the storage of massive volumes of retrospective paper-based patient records are dominant concerns for São João Hospital Center (SJHC). These problems must be considered in the adoption of an Electronic Patient Record (EPR) in order to ensure that hospitals and patients fully benefit from the technological investments. The contribution of this chapter is the design and conduction of a (re)use study, which consisted of an analysis of the paper-based records management activities and of the patients’ records content. A survey on the (re)use of the paper-based patient records has been conducted in order to characterize the (re)use in terms of objective and type of hospital encounter, and documents accessed were identified and organized in an access frequency table. The results support the paper-based patient records strategy to implement in SJHC integrated in the Hospital EPR adoption project.