Examination of the context of record creation, maintenance, and use is a valuable tool which allows the archivist to build a body of knowledge regarding archival records and their creators. Such knowledge enables the archivist to make informed decisions in all realms of archival practice. This discussion focuses upon the women's organization, undertaking a case study of three organizations in Vancouver, British Columbia in order to provide information about their record keeping practices. The case study employs open-ended focus interviews, observation, and document analysis, where provided. Participants are selected based upon their involvement in the creation, maintenance, and use of records in their respective organizations. They are asked to provide information as to the administrative history of the organization and to describe the processes by which they receive, create, use, organize, maintain, and destroy records. Participants are also asked to characterize their organization and its record keeping practices as they relate to the concept of a women's organization. A framework for analysis is established, which allows for further characterization of each women's organization. This framework addresses the voluntary nature of most women's organizations, as well as their unique processes and forms. Three models are presented which allow for further characterization of the history, structure, and practices of each organization. The distinctive internal processes, forms, and record keeping practices of the Women's International League for Peace and Freedom, the Western Businesswomen's Association, and the West Coast Women's Legal Education and Action Fund are presented. The thesis concludes by providing recommendations regarding further explorations of record creation, maintenance, and use and their value for the archival profession. / Arts, Faculty of / Library, Archival and Information Studies (SLAIS), School of / Graduate

Open government relies heavily on reliable records to uphold service delivery and access to information. Without proper records management of business transactions and activities of an organization, the primary objective of openness becomes obscured and difficult to achieve. Within the digital space and environment, establishing good record- keeping procedures is challenging to both paper and e-records, because of a scarcity of clarity in the processes and measures in place, as well as as a result of lack of suitable ICT infrastructure plus skilled human resources to help facilitate good e-records management. The aim of this research was to provide a structure for the integration of records into open government initiatives in Botswana with the aim of assisting access to information and service delivery, and a subsequent transparent, accountable and open government. This is a mixed research study framed within the interpretivism epistemological inquiry model, and used Open Government Implementation Model and Action research being a theoretical lense in this study. Document analysis was used to gather information, complemented by interviews and questionnaires with participants and respondents alike purposively selected from the Ministry of Local Government and Rural Development (MLGRD). According to the findings, the legislative as well as regulatory frameworks in order to manage both paper and e-records were available in Botswana although inadequate. Similarly, the research showed that legislation that gives the citizens access to information and subsequently make compulsory for organizations to avail information upon request is absent. Furthermore, it was established through the study findings that information management practitioners are particularly are ill equipped and inexperienced to manage paper and electronic records. Due to the inavailability of ICT infrastructure to help facilitate both paper and e-records management was noted. In addition, open government initiatives were identified as producing e- records, but there were no defined protocols to help aid in their management. Therefore, this weakness can be addressed by integrating records management into open government initiatives, and be able to utilize suitably identified Enterprise Content Management (ECM) or Electronic Document and Records Management System (EDRMS). Currently, open government remains ensured through the reliance of only open government initiatives, without leveraging on good records management. This project study suggests a structure to integrate records management into open government initiatives anchored on legislation and regulatory frameworks with the confidence that its employment would support better information and service accessibility by the citizens. Finally, because of poor records management and a lack of legislation that encourage access to information, there will be continued reliance on the discretion of records professionals by the citizens to have information access. Similarly, without proper records management procedures, Information Communication Technologies (ICTs) will remain underutilized. Thus, it is a recommendation that MLGRD should develop proper records management procedures to guide and improve on the management of records. A further study to establish the level of e-readiness of the Botswana government to fully automate and guarantee the success of open government is recommended. / Information Science / D. Litt et Phil (Information Science)

Indiana University-Purdue University Indianapolis (IUPUI) / Reducing medical error remains in the forefront of healthcare reform. The use of health information technology, specifically the electronic health record (EHR) is one attempt to improve patient safety. The implementation of the EHR in the Emergency Department changes physician workflow, which can have negative, unintended consequences for patient safety. Inaccuracies in clinical documentation can contribute, for example, to medical error during transitions of care. In this quasi-experimental comparison study, we sought to determine whether there is a difference in document quality, error rate, error type, cognitive load and time when Emergency Medicine (EM) residents use paper charts versus the EHR to complete physician documentation of clinical encounters. Simulated patient encounters provided a unique and innovative environment to evaluate EM physician documentation. Analysis focused on examining documentation quality and real-time observation of the simulated encounter. Results demonstrate no change in document quality, no change in cognitive load, and no change in error rate between electronic and paper charts. There was a 46% increase in the time required to complete the charting task when using the EHR. Physician workflow changes from partial documentation during the patient encounter with paper charts to complete documentation after the encounter with electronic charts. Documentation quality overall was poor with an average of 36% of required elements missing which did not improve during residency training. The extra time required for the charting task using the EHR potentially increases patient waiting times as well as clinician dissatisfaction and burnout, yet it has little impact on the quality of physician documentation. Better strategies and support for documentation are needed as providers adopt and use EHR systems to change the practice of medicine.

Submitted in fulfillment of the requirements of the degree of Master of Technology: Information Technology, Durban University of Technology, 2013. / In this study, an investigation was conducted to determine an appropriate lightweight framework that could adequately support Very Small Enterprises (VSEs) in documenting their daily business transactions. The VSEs play a significant role in the socioeconomic development of nations by providing employment opportunities. They contribute to the Gross Domestic Product (GDP) and provide a platform for entrepreneurial skills advancement. However, VSEs have very little access to innovative Information and Communication Technology (ICT) that could help to address the unique challenges that prohibit their growth and sustainability. In many instances, the documentation of VSEs business transactions is still lacking. This deficiency promotes insufficient, unreliable and untraceable business transaction records which ultimately affect the smooth growth and sustainability of VSEs. Mobile technology provides the VSEs with a unique opportunity because of its support for mobility and low costs of system procurement. Moreover, mobile technology can enable easy connection, access and retrieval of VSE services even in the resource constrained environments anytime and anywhere. However, the inherent limitations of mobile devices such as device size, storage size, computing power and battery lifespan have forced many of the existing ICT business applications to continually rely on desktop computers. The desktop computer applications are huge, complex and not compatible with the current mobile devices. The Design Science Research (DSR) method was used to understand how VSEs conduct their daily business transactions, discover essential factors that influence the business processes of VSEs and derive a lightweight framework for mobile documentation of VSE business transactions. The lightweight framework was prototyped as ICT artefact and evaluated to determine the adoption of mobile applications by VSEs for documentation of daily business transactions. The evaluation results revealed the developed lightweight framework to be effective for mobile documentation of VSEs business transactions.

Thesis (MPA)--University of Stellenbosch, 2011. / ENGLISH ABSTRACT: The research study assessed records management practices in the Limpopo Department of Agriculture (LDA), with the focus being on human resources records. Human resources records management practices were assessed in four key performance areas, namely: policy and regulatory framework, storage requirements, integrity of paper-based and electronic records, and efficiency and effectiveness of the registry system. The assessment tool, as prescribed in the Best Practice Model for Keeping and Managing Paper-Based Employee Records, was used. Research findings showed that LDA's performance in terms of records management practices do not comply with the set policies and regulatory framework and that the storage conditions are insecure. Research findings were evaluated and possible strategies for improving the management of human resources records are recommended. The adoption of awareness campaigns for staff, a coordinated training programme as well as the provision of support of top management, are some of the strategies recommended. / AFRIKAANSE OPSOMMING: In hierdie navorsingstudie is rekords van bestuurpraktyke in die Limpopo Departement van Landbou (LDL) geassesseer, met die fokus op menslikehulpbronrekords. Die menslikehulpbronrekords is geassesseer op grond van vier kernprestasie-areas, naamlik die beleids- en regulatoriese raamwerk, bergingsvereistes, integriteit van papiergebaseerde en elektroniese rekords, en doeltreffendheid en effektiwiteit van die registerstelsel. Die assesseringstelsel soos voorgeskryf deur die Best Practice Model for Keeping and Managing Paper-Based Employee Records is gebruik. Navorsingsbevindings het getoon dat die LDL se prestasie ten opsigte van rekordbestuurpraktyke nie voldoen aan beleide nie en dat ‟n regulatoriese raamwerk en veilige bergingstoestande nie bestaan nie. Navorsingsbevindings is geëvalueer en moontlike strategieë om die bestuur van menslikehulpbronrekords te verbeter, is aanbeveel. Die ingebruikneming van bewusmakingsveldtogte vir personeel, 'n gekoördineerde opleidingsprogrm en ook die verskaffing van steun deur topbestuur is van die strategieë wat aanbeveel word.

Thesis (MBA (Business Management))--University of Stellenbosch, 2009. / ENGLISH ABSTRACT: A Document Management System (DMS) can help businesses speed-up as well as reduce the number of mundane and repetitive tasks relating to documents. These benefits can assist management cut costs, reduce errors, automate frequently performed tasks as well as store information electronically in a safe and accessible way. Making IT Simple (the business) is a start-up business that has entered into a partnership agreement with INVU, Europe's fastest growing DMS Software developer (INVU, 2008). This agreement allows the business to sell INVU software without restriction by volume or geography to all sectors of industry. INVU products are designed to make business administration, and especially managing documents a simple and efficient process. These two principle product features support the business' objectives and marketing push by delivering easy-to-use software that helps customers reduce costs by speeding-up as well as reduce the number of daily administrative tasks performed using documents. In order to establish which market sector to target, the Directors conducted an industry analysis (Appendix I) which has identified opportunities in the farming and agricultural Sector. The three primary reasons are: 1) Sustainable sector growth of 30% per annum (UK Agriculture, 2007), 2) no known DMS competition within Farming and 3) the Directors have an established Network and detailed knowledge of the sector. Although farming and agriculture will be the main focus of marketing activity and communication, other industries, such as property letting agencies, are also seen as future opportunities for the business. Target Market and Projections Market Research is based upon 138 questionnaire responses that have enabled the Directors to develop a product package which combines the product, a DMS license and software, together with the necessary hardware and maintenance support sufficient to satisfy the target market's needs. The target market is defined as a farm business, predominantly farming crops or cattle and/or sheep from between 41 and 80 hectares of productive land. It has up to 20 full time employees, half of whom are involved in the business' administration. This admin comprises mainly of financial accounts and Government Department returns which are processed on as many as two computers which have email, Microsoft Office and accounting software packages loaded on. For security and access the target market store their records in filing cabinets for up to 15 years, mostly in paper form. A priority for business' administration within this market is the simplicity and easy access of its records and with all records being in one place. The sales forecasts of 7, 16 and 30 units over the first three years 2009, 2010 and 2011 respectively are deemed achievable by the Directors, having received reassurance from both formal interviews (Radley, 2008) and conversations with potential customers. The business sees their target market strategy and their lean cost base as being their competitive advantage together with the impression that none of INVU's DMS competitors are currently focussed upon the agriculture sector. This gives the business a potential first mover advantage which will be supported by leveraging the marketing efforts and the existing network of contacts to deliver the specifically designed sales process for the target market. The suite of products, which are leased by the customer over 36 months, cost £15,016 and have a Gross Profit of 58%. This gross profit then funds the running and maintenance of the support service provided by the company. Return on Equity over the 3 years of the Business Plan is strong at 60% given that there is a loss of £50,000 in Year 1. Year two generates a small profit of £24,000 with a healthy £64,000 in Year 3 onwards. Return on sales is 10% in year 2 growing to 14% in year 3. Break even point is in July 2011 (month 31) with the business cash positive in August 2010 (month 20). The financial risks are calculated as low due to the lease funding providing cash within 14 days of a signed document, plus there is no cash risk as the requirement to hold inventory is negligible. The balance sheet requires equity funding of £40,000 which is provided by the two directors at £20,000 each, plus a 60 month working-capital bank loan which is forecast to be repaid on month 25. There are 46,000 farms in UK so, in this market sector alone there are potentially 9,200 (20%) sales presentations to be completed based upon the market survey data. On projected performance this would currently take the business 460 months to complete. The business case shows an improving performance month on month based upon an improvement in sales skills, product portfolio and brand awareness. The two employees Edward Gibbs and Mathew Easterbrook, both of whom are Directors, have each invested £20,000 in equity in order to start-up the business. They have 28 years of management experience between them and offer complementing specialities in the IT, sales, farming and finance areas. Their business objectives are to generate cash and satisfy customer needs by selling products at the right price with a sustainable gross profit margin whilst being commercially aggressive on costs. Their simple and equitable company structure reflects their excellent relationship and the balance of power is shared equally. The product is a compliment of hardware, software and support service that is tailored to meet a customer's needs (Table 1). / AFRIKAANSE OPSOMMING: 'n Dokumentbestuurstelsel (DBS) kan organisasies help om meer effektief sake te doen en om die aantal eenvoudige en herhalende take met die hantering van dokumente te verminder. Hierdie voordele kan bestuur help om koste te verminder, foute te verminder, gereelde take te outomatiseer en ook om inligting elektronies in 'n veilige en maklik bereikbare plek te stoor. Making IT simple (die onderneming) is 'n nuwe onderneming wat in 'n vennootskap ooreenkoms met INVU, Europa se snel groeiendste DBS sagteware verskaffer, aangegaan het. Hierdie ooreenkoms laat die ondememing toe om INVU sagteware te verkoop in alle industriee met geen bepreking op volumes of geografiese areas nie. INVU produkte is ontwerp om besigheid administrasie, en spesifiek die bestuur van dokumente, 'n eenvoudige en effektiewe proses te maak. Hierdie twee beginsels ondersteun die onderneming se doelwitte en bemarking deur die lewering van eenvoudig-om-te-gebruik sagteware wat kliente help om kostes te verlaag deur vinniger prosesse sowel as verminderde daaglikse roetine administratiewe dokumentering take. Ten einde die marksegment wat geteiken moet word te bepaal het die direkteure 'n industrie analise (Aanhangsel I) gedoen wat geleenthede in die boerdery en landbou sektore uitgewys het. Die drie primere redes is: 1) Substansiele sektor groei van 30% per jaar (UK Agriculture, 2007), 2) geen bestaande DBS wat tans aktief in die mark is nie en 3) die direkteure het 'n gevestigde netwerk en detail kennis van die sektor. Alhoewel boerdery en landbou die hooffokus van die bemarkings en kommunikasie aktiwiteite gaan wees sal ander industriee, soos eiendoms en verhurings agentskappe, ook gesien word as toekoms geleenthede vir die onderneming. Marknavorsing is gebaseer op 138 voltooide vraelyste wat die direkteure in staat gestel het om 'n produk pakket bestaande uit 'n DBS lisensie en sagteware saam met die nodige hardeware en ondersteunings saam te bondel, ten einde aan die mark se behoefte te voorsien. Die teikenmark is gedefinieer as boerdery ondernemings wat primer boer met gewasse en/of skape op tussen 41 en 80 hektaar produktiewe landbougrond. Die boerdery het ongeveer 20 voltydse werknemers waarvan die helfte met die onderneming se administrasie te doen het. Die administrasie bestaan meestal uit finansiele take en Regerings Departemente se verslae wat geprosesseer word op tot twee rekenaars met toegang tot Microsoft Office en 'n rekenkundige sagteware pakket. Vir sekuriteit en maklike toegang tot hulle dokumente stoor die tipe ondernemings hulle dokumente in liasseerkabinette vir tot 15 jaar, meestal in papier formaat. 'n Prioriteit vir ondernemings se administrasie binne die teikenmark is eenvoud en maklike toegang tot hulle dokumente, asook die sentrale berging van dokumente op een spesifieke plek. Die verkoops vooruitskattings vir 7, 12 en 30 eenhede oor die eerste drie jare 2009, 2010 en 2011, word gesien as realisties en bereikbaar deur die direkteure na aanleiding van formele onderhoude (Radley, 2008) en gesprekke met potensiele kliente. Die onderneming sien hulle teikenmark strategie en hulle lae koste struktuur as hulle kompeterende voordeel tesame met die feite dat geen van INVU se DBS kompeteerders huidiglik op die landbou sektor fokus nie. Die gee die ondememing die potensiele eerstetoetreder voordeel in die landbou industrie. Dit sal ondersteun word deur die hefboom effek van die bemarkings pogings komende uit die bestaande netwerk van kontakte om gefokusde verkoopsprosesse in die teikenmark uit te voer. Die suite van produkte, wat gehuur word deur die kliente oor 'n tydperk van 36 maande, kos £15,016 en het 'n bruto wins marge van 58%. Hierdie bruto wins befonds die bedryf en ondersteuningsdienste van die onderneming. Die opbrengs op ekwiteit oor die drie jaar tydperk van die besigheidsplan is stewig op 60% gegewe dat daar 'n verlies van £50,000 in Jaar 1 plaasvind. Jaar 2 genereer 'n klein wins van £24,000 met 'n stewige wins van £64,000 in Jaar 3. Opbrengs op verkope is 10% in jaar 2 en groei tot 14% in jaar 3. Die gelykbreekpunt is Julie 2011 (maand 31) en die onderneming is kontant positief vanaf Augustus 2010 (maand 20). Die finansiele risiko is laag as gevolg van die huur inkomste wat kontant binne 14 dae na die teken van 'n ooreenkoms genereer en ook omdat daar geen kontant risiko is met die dra van voorraad nie. Die balansstaat ekwiteit benodig 'n aanvangsbelegging van £40,000 wat voorsien word deur die twee direkteure teen £20,000 elk, saam met 'n 60 maande werkskapitaal bank lening wat geprojekteer word om volopbetaal te wees teen maand 25. Daar is tans 46,000 plase in die VK en dus, in die marksegrnent alleen, 9,200 (20%) verkoops voorleggings gebaseer op die markanalise data. Op die geprojekteerde werkstempo sal dit ongeveer 460 maande neem om te voltooi. Die besigheidmodel toon groeiende verrigting op 'n maand tot maand basis gebaseer op 'n verbetering in verkooptegniek, produk portefeulje en produk kennis. Die twee werknemers Edward Gibbs en Mathew Easterbrook, wat ook die direkteure is, het elk £20,000 aanvangskapitaal geinvesteer ten einde die onderneming op die been te bring. Hulle het 28 jaar bestuurservaring en het komplimenterende vermoens in die IT, verkope, boerdery en finansiele areas. Hulle besigheid doelwit is om kontant te genereer en kliente se behoeftes te bevredig deur die verkope van produkte teen die korrekte prys teen 'n volhoubare bruto wins. Hulle eenvoudige maatskappy struktuur reflekteer hulle uitstekende verhouding en die magsbalanse is eweredig versprei. Die aanbod aan die mark is 'n komplimenterende suite van hardeware, sagteware en steundienste wat aangepas word om aan 'n klient se behoeftes te voldoen (Tabel 1).

在近現代總統制國家中，「總統」所產生之文物，不論在歷史、經濟、社會、教育、科學及文化等層面，皆具有高度保存價值，記錄總統執政期間之施政表現，見證國家各階段之發展歷程，為國家與全民共享之珍貴資產，後代子孫的歷史寶藏。然而國內自行憲以來，歷經蔣中正總統、嚴家淦總統、蔣經國總統、李登輝總統以及現任之陳水扁總統等五位總統，卻仍未建立總統文物管理之機制，致使歷任總統文物歸屬權責不明，亦缺乏相關之管理規範，造成行憲以來歷任總統文物散佚各處等情況。鑑於美國在總統文物管理實務方面以「總統圖書館」之機制，系統化地典藏總統於任內及任期前後所產生之文物，並有效地開放提供社會大眾應用，本研究希冀取法美國總統文物管理之特點，並配合國內現實環境與現況，提出適用於我國之總統文物管理之建議，以供日後發展總統文物管理機制時之參酌。 本研究採以調查法與深度訪談法進行研究。一方面藉由對蔣中正總統、嚴家淦總統以及蔣經國總統所產生之文物進行實際調查，以瞭解上述三者於內涵、來源、產生方式以及架構等方面之現況；另一方面則運用引導性取向的深度訪談法，訪談國內總統文物之使用者與管理者共計10位，蒐集受訪者對於總統文物管理在定義與範圍、功能導向、管理模式以及法源依據等面向之意見。而後整合實地調查與深度訪談之結果，提出適用於我國之總統文物管理建議。 由實際調查結果發現，我國行憲以來歷任總統文物目前主要典藏於國史館，包括有蔣中正總統檔案、嚴家淦總統檔案以及蔣經國總統檔案等。該館所典藏之總統文物在內容範圍方面涵括十分廣泛，但是在完整性方面則仍有不足之處；而該館所採用之整編方式，乃依循文物原移轉接收時之架構，並未運用現代檔案管理原則重新進行整理編排。另一方面，由深度訪談結果發現，使用者與管理者等不同背景之受訪者對於「總統文物」與「總統檔案」之名稱適用性與定義看法紛歧，但是卻普遍認同「總統個人文件」之名稱，亦認可總統文物可依歸屬權分為公務及私人兩類，並認為兩者間應有不易劃分的模糊地帶。此外，多數受訪者同意我國總統文物管理功能應以典藏與應用為導向，且宜採行集中制管理，同時也提出總統文物管理機關定位不明以及缺乏相關法源依據等意見。 依據研究結果，本研究由以下四方面提出幾項建議。一、實務面：（一）於總統文物產生階段即展開管理工作；（二）回溯徵集現行總統文物中遺缺之部分；（三）積極廣徵總統個人文件。二、應用面：（一）提供總統文物多樣化之應用服務；（二）提升總統文物應用服務之品質。三、制度面：（一）採行集中制管理總統文物；（二）授權國家檔案管理機構負責總統文物之主管與典藏事宜。四、法制面：（一）儘速制訂總統文物管理相關法令；（二）透過法源依據建立總統文物管理規範；（三）提升總統文物管理者與使用者之法律素養。

Since the 1990 the use of Electronic Patient Records (EPR) in health services has become increasingly prevalent world wide. EPR has become an important aspect of the continuous improvement of patient care. Transferring all patient records from paper based to electronic is now a priority for many health services. The research reported in this thesis is sponsored by Hamad Medical Corporation (HMC) to provide opportunity to explore the potential role for EPR in the Medical Records Department. The study has been designed to gain better understanding of the users perspectives with regard to the use of patient records. In order to analyse and understand the complex dynamic involved in the management and use of patient records, it was recognised that systems thinking offered an appropriate framework for this research. Soft System Methodology (SSM) was therefore applied to the analysis of the data and used to inform the development of a conceptual model. Using SSM in combination with the structured questionnaire survey and telephone semi-structured interview, triangulation of methods was achieved. Use of these generated rich data revealing for example the general dissatisfaction expressed with the existing manual patient records system, the lack of confidentiality, poor legibility, shortage of space and the frequent misfiling of records. The need to address these problems has informed the strategic plan for the development and implementation of EPR for HMC. The research has successfully addressed the stated aims and research questions and guided the formulation of proposals for improvements.

Objetivo: Avaliar a satisfação e expectativas dos pacientes e médicos antes e depois da implantação de um registro médico eletrônico (RME) de pacientes no ambulatório de clínica médica de um hospital universitário. Métodos: Foram realizadas 389 entrevistas com pacientes e 151 com médicos antes e depois da implantação de um RME comercial no ambulatório de Clínica Médica do Hospital das Clínicas da Universidade de São Paulo, Brasil. Os médicos foram categorizados por seus anos de graduação (10 anos ou menos e mais de 10 anos). As respostas ao questionário dadas pelos médicos foram classificadas como favorável ou contra o uso de RME, antes e depois da implantação do sistema, recebendo 1 ou 0 pontos, respectivamente. A soma destes pontos gerou uma pontuação analisada por regressão múltipla para determinar quais os fatores que contribuem para a aceitação de RME pelos médicos. Para se avaliar o comportamento de pacientes e médicos em um período em que a implantação já havia entrado na rotina, realizou-se uma terceira etapa de entrevistas com pacientes e médicos. Resultados: O grau de satisfação do paciente era o mesmo antes e depois da implantação (p > 0,05). O tempo de espera para ser atendido foi maior após a implantação de RME (p < 0,0001), embora a percepção dos pacientes tenha apontado para uma direção diferente (p=0,0186). Médicos formados há menos de 10 anos já tinham usado os registros eletrônicos em outros hospitais e clínicas (p=0,0141). Estes médicos tinham expectativas mais positivas antes da implantação (p=0,0018). Este otimismo foi reduzido após a implantação, devido ao mau funcionamento do sistema durante a fase inicial (p=0,0229). A utilização do RME foi maior pelos médicos mais jovens (p < 0,0001). Na terceira avaliação os pacientes mostraram-se muito satisfeitos com o atendimento (porcentagem de mais de 90%). Percebiam a utilização do computador durante a consulta e valorizavam essa utilização. Os médicos com 10 anos ou menos de graduação, percebiam e valorizavam mais as facilidades do registro eletrônico e o utilizavam mais. Em 11 de 18 questões específicas sobre o desempenho de tarefas clínicas os médicos mais jovens julgaram mais fácil utilizar o RME, do que os médicos mais antigos p < 0,05. Questionados especificamente sobre a satisfação com o RME, os médicos mais jovens responderam \"boa\" e \"excelente\" em maior proporção do que os com mais de 10 anos de formados (p=0,0011) / Objective: To evaluate the satisfaction and expectations of patients and physicians before and after the implementation of an electronic medical record (EMR) in internal medicine outpatient clinic of a university hospital. Methods: We conducted 389 interviews with patients and 151 with doctors before and after the implementation of a commercial RME in internal medicine outpatient clinic of the Hospital das Clinicas, University of São Paulo, Brazil. Doctors were categorized by their graduate years (10 years or less and more than 10 years). The answers to the questionnaire given by doctors were classified as favorable or against the use of EMR, before and after the implementation of the system, receiving 1 or 0 points, respectively. The sum of the points generated scores analyzed by multiple regression to determine the factors that contribute to the acceptance of EMR by doctors. To evaluate the behavior of patients and doctors in a period when the implementation had already entered the routine, a third stage of interviews with patients and doctors was carried out. Results: The degree of patient satisfaction was the same before and after implantation (p > 0.05). The waiting time to be attended was increased after the implementation of EMR (p < 0.0001), although the perception of patients has pointed to a different direction (p=0.0186). Doctors graduated less than 10 years had already used the electronic records in other hospitals and clinics (p=0.0141). These doctors had more positive expectations before implantation (p=0.0018). This optimism was reduced after implantation, due to system malfunction during the initial phase (p=0.0229). Utilization of EMR was higher by younger physicians (p < 0.0001). The third evaluation showed the patients were very satisfied with the service (over 90%). They noticed the use of the computer during the consultation and valued such use. Doctors with 10 or less graduation years, perceived and valued more the facilities of electronic medical records and used more. In 11 of 18 specific questions about the performance of clinical tasks younger doctors deemed it easier to use the electronic medical record, than older physicians (p < 0.05). When asked specifically about satisfaction with EMR, younger physicians responded \"good\" and \"excellent\" in greater proportion than the old physicians (p=0.0011)

As unidades básicas de saúde utilizam tecnologias de informação e comunicação (TIC) desde o ano de 1997, com a finalidade de potencializar a comunicação entre os serviços. A compreensão e conhecimento dos profissionais que as utilizam é fundamental para obter-se a qualidade do cuidado integral ao paciente. Esta pesquisa teve como objetivo descrever a percepção dos profissionais de saúde sobre a implementação e o uso do Prontuário Eletrônico do Paciente (PEP). Estudo transversal, com abordagem quantitativa e qualitativa breve, tendo como campo de estudo os profissionais que atuam na Atenção Primária em Saúde (APS) do município de Esteio na região Metropolitana de Porto Alegre (RS). Para a avaliação do prontuário eletrônico foi utilizado um questionário com perguntas e respostas assertivas padronizadas numa escala de concordância do tipo Likert. As análises descritivas preliminares apresentaram as variáveis contínuas em média e desvio padrão e, as categóricas, em frequência absoluta e relativa. O teste de confiabilidade de Cronbach's Alpha foi aplicado, preliminarmente, ao instrumento de avaliação do Prontuário Eletrônico. A análise fatorial foi realizada com o objetivo de identificar uma menor quantidade de variáveis que apresentem uma identidade comum. Inicialmente, para verificar a presença de correlações entre variáveis foi utilizado o teste de Bartlett de esfericidade. Após foi utilizada a Medida de Adequação da Amostra (MAS) para quantificar o grau de intercorrelações entre as variáveis e a adequação da análise. A percepção dos profissionais da APS frente a implementação do prontuário eletrônico do paciente demonstrou ter associação com as capacitações e informações recebidas e com as adequações realizadas nos prontuários. O pessoal da recepção foi a categoria profissional (p=0,001) que demonstrou ter maior necessidade de acesso a capacitações e informações sobre a implementação do prontuário assim como aqueles que atuam no município há menos de dois anos (p=0,024). Os enfermeiros demonstraram que a adequação do prontuário (p= 0,025) pode ser um fator a ser aprimorado para a implementação do PEP. Embora o prontuário eletrônico do paciente tenha qualificado a assistência, os profissionais de saúde que o utilizam ainda sentem necessidade de maior treinamento, capacitações e informações sobre esta ferramenta visando uma melhor qualidade na assistência prestada aos usuários do SUS. / Basic health units have been using information and communication technologies (ICT) since 1997, in order to enhance communication between services. The understanding and knowledge of the professionals who use them is fundamental to obtain the quality of integral care to the patient. This study aimed to describe the perception of health professionals about the implementation and use of the Electronic Patient Record (PEP). This is a cross-sectional study with a brief quantitative and qualitative approach, with professionals working in Primary Health Care (APS) in the city of Esteio in the Metropolitan Region of Porto Alegre (RS) as a field of study. For the evaluation of the electronic medical record, a questionnaire with standardized assertive questions and answers was used on a Likert-type agreement scale. The preliminary descriptive analyzes presented the continuous variables in mean and standard deviation, and the categorical variables, in absolute and relative frequency. The Cronbach's Alpha reliability test was applied, preliminarily, to the electronic Record evaluation instrument. Factor analysis was performed with the objective of identifying a smaller number of variables that present a common identity. Initially, Bartlett's sphericity test was used to verify the presence of correlations between variables. Afterwards the Sample Adequacy Measure (MAS) was used to quantify the degree of intercorrelations between the variables and the adequacy of the analysis. The perception of APS professionals regarding the implementation of the patient's electronic record showed to be associated with the training and information received and with the adjustments made in the medical records. The reception staff was the professional category (p = 0.001) who showed a greater need for access to training and information about the implementation of the medical record, as well as those who worked in the municipality for less than two years (p = 0.024). The nurses demonstrated that the adequacy of the chart (p = 0.025) may be a factor to be improved for the implementation of PEP. Although the patient's electronic medical record has qualified care, health professionals who use it still feel the need for more training, skills and information on this tool aiming at a better quality of care provided to SUS users.