Creación de modelo de historial clínico de GNU Health para su implementación en el Níspero, Santa Bárbara.
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Date
2026-04-05
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Publisher
Universidad Tecnológica Centroamericana UNITEC
Abstract
La implementación de Registros Clínicos Electrónicos (RCE) no solo asegura una administración eficiente de la información confidencial de los pacientes, sino que también garantiza la seguridad de dicha información. Este enfoque busca salvaguardar la privacidad de los pacientes y garantizar el cumplimiento de estándares éticos y legales.Para lograr lo propuesto, se plantea la utilización de un software que permita crear un registro de historia clínica en el cual se incluyan múltiples datos sobre el paciente e historial médico.Metodología: Estudio exploratorio y observacional realizado en el Centro Integral de Salud del Níspero (CIS). Siendo el sujeto principal de estudio la historia clínica, se definió y delimitó la muestra considerando los formatos y hojas de evaluación utilizadas por el personal clínico del centro de salud del municipio. Se delimitó la muestra a una cantidad mínima de 6 expedientes de pacientes correspondientes a cada uno de los seis formatos manejados en el centro. Dichos formatos son: Instrumento para la atención de puérperas, Atención del recién nacido y menor de 2 meses de edad, Atención del niño/niña de 2 meses a 4 años, Historia Clínica Perinatal, Historias Clínicas Pediátricas (niño/niña) y Formato de referencias.Se diseñó una hoja de cálculo en Excel como herramienta para realizar un análisis comparativo entre los campos requeridos y los presentes en los diversos módulos de GNU Health. En esta hoja se elaboró un listado detallado que incluye factores de cumplimiento, su ubicación dentro de los módulos disponibles y observaciones para abordar la ausencia de campos.El objetivo es minimizar las modificaciones necesarias a partir de las conclusiones de la investigación, creando así una interfaz completa pero fácil de utilizar, que satisfaga cada una de las necesidades identificadas durante el análisis de la importancia de los campos.Un resultado final señala un porcentaje total del 83 por ciento de adaptabilidad de los formatos actuales manejados en el CIS, lo cual convierte a GNU Health en una opción viable para la implementación de HCE en el CIS de El Níspero.
The implementation of Electronic Health Records (EHRs) not only ensures efficient management of patients' confidential information but also guarantees the security of such information. This approach aims to safeguard patients' privacy and ensure compliance with ethical and legal standards.To achieve this goal, the use of software that allows the creation of a medical history registry, including multiple patient data and medical history, is proposed.Methodology: An exploratory and observational study was conducted at the Integral Health Center of El Níspero (CIS). With clinical history as the main subject of study, the sample was defined and delimited considering the formats and assessment sheets used by the clinical staff of the health center. The sample was delimited to a minimum of 6 patient records for each of the six formats managed in the center.These formats are: Instrument for the care of puerperal women, Care of the newborn and child under 2 months of age, Care of the child aged 2 months to 4 years, Perinatal Clinical History, Pediatric Clinical Histories (child), and Referral Format.An Excel spreadsheet was designed as a tool for conducting a comparative analysis between the required fields and those present in the various GNU Health modules. In this spreadsheet, a detailed list was elaborated that includes compliance factors, their location within the available modules, and observations to address the absence of fields.The objective is to minimize the necessary modifications based on the research conclusions, thus creating a comprehensive but easy-to-use interface that satisfies each of the needs identified during the analysis of the importance of the fields.The result indicates a total adaptability percentage of 83 percent of the current formats managed in the CIS, making GNU Health a viable option for the implementation of EHRs in the CIS of El Níspero.
The implementation of Electronic Health Records (EHRs) not only ensures efficient management of patients' confidential information but also guarantees the security of such information. This approach aims to safeguard patients' privacy and ensure compliance with ethical and legal standards.To achieve this goal, the use of software that allows the creation of a medical history registry, including multiple patient data and medical history, is proposed.Methodology: An exploratory and observational study was conducted at the Integral Health Center of El Níspero (CIS). With clinical history as the main subject of study, the sample was defined and delimited considering the formats and assessment sheets used by the clinical staff of the health center. The sample was delimited to a minimum of 6 patient records for each of the six formats managed in the center.These formats are: Instrument for the care of puerperal women, Care of the newborn and child under 2 months of age, Care of the child aged 2 months to 4 years, Perinatal Clinical History, Pediatric Clinical Histories (child), and Referral Format.An Excel spreadsheet was designed as a tool for conducting a comparative analysis between the required fields and those present in the various GNU Health modules. In this spreadsheet, a detailed list was elaborated that includes compliance factors, their location within the available modules, and observations to address the absence of fields.The objective is to minimize the necessary modifications based on the research conclusions, thus creating a comprehensive but easy-to-use interface that satisfies each of the needs identified during the analysis of the importance of the fields.The result indicates a total adaptability percentage of 83 percent of the current formats managed in the CIS, making GNU Health a viable option for the implementation of EHRs in the CIS of El Níspero.
Keywords
Adaptabilidad, Historia clínica, Interfaz, Registros electrónicos, Salud