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In the health field, it is known that records and information accumulated during the course of patient care are filed in the form of individual records. As it is a primary source of information, it aggregates knowledge related to administrative issues, being able to corroborate in the teaching and research process and even brings legal issues. (RIBEIRO et al., 2018). For a long time, the handwritten medical record was the main instrument for storing data of patients served in the health services. Despite being a great source of information, the handwritten record presents innumerable fragilities when compared to the electronic record, being susceptible to deterioration, loss of data, need of physical space for its storage and for not being sustainable. (RIBEIRO et al., 2018). Currently the technology is being used to improve hospital care through an information system and electronic records (LAHM; CARVALHO, 2015). Thus, data require a complex means of storage, processing, sharing and recovery (COLLETI; ANDRADE; CARVALHO, 2018). The electronic patient record (EHR) is part of this strategy that prioritizes the recording of health and disease data, being indispensable for multidisciplinary monitoring. (LAHM; CARVALHO, 2015). Through the use of PEP, it becomes possible to integrate patient data, whether laboratory, clinical or imaging data, allowing a holistic and uncomplicated view during access (MUYLDER et al., 2017). Moreover, it acts as an important tool for the improvement of safety and quality indicators in patient care, as well as in cost optimization (COLLETI; ANDRADE; CARVALHO, 2018). This resource provides the history of care and hospitalizations, ensuring the evolution of each case with a detailed view of history and clinical evolution, including in emergency situations (LAHM; CARVALHO, 2015). Regarding the performance of health professionals in emergency and emergency situations, it is understood that they should act in an agile and skillful way, in search of the hemodynamic balance of the patient. Therefore, time optimization is fundamental in this process (CORDEIRO et al., 2019). The lack of information about the patient in these situations results in difficulties during the decision making by the health team. With the use of PEP, a previous hospitalization, provides subsidies for quick and effective intervention to the patient, as well as allows the continuity of treatment (JABBUR, OSHIRO, FAGUNDES, 2020; CORDEIRO et al., 2019). However, the use of PEP can face obstacles due to the high financial investment with hardware, software, need for training of professionals, slowness of the system, insufficient number of computers for access, and even cause a deficiency in the relationship multiprofessional teampatient (RIBEIRO et al., 2018). OBJECTIVE: To describe the performance of the nursing in the use of the electronic record as strategic tool to impel the management of the quality of the assistance to the health. METHODOLOGY: It is a report of experience of nursing residents in the area of urgency and emergency who experience the practice of the electronic record in a tertiary and university level hospital, located in northern Paraná. This hospital attends cases of high complexity from several areas, both clinical and surgical, has a Bone Marrow Transplant Unit (BMT), Burned Therapy Center (CTQ) and is currently a reference hospital for Coronavirus Disease (COVID-19). The institution attends patients from about 250 cities in the state of Paraná and more than 100 cities in other states, including São Paulo and Mato Grosso. RESULTS: The patient's electronic record allows the registration of health care including personal data, anthropometrics, vital signs such as heart rate, respiratory rate, non-invasive blood pressure, temperature and pain, this as the fifth vital sign according to the Brazilian Society for the Study of Pain. Other records are also part of this chart such as the diet prescribed to the patient, intestinal and bladder eliminations, these quantified by milliliter (ml) or proportion by crosses, among others. Moreover, it is possible the accomplishment of the scales of Morse, Braden and Fugulin for scores that will guide the planning of nursing assistance. The scale of Morse, created in 1989 by Janice Morse, concerns the diverse factors that influence the risk of fall of the patient. Composed by six evaluation criteria, being these the previous history, the secondary diagnosis, Brazilian Journal of health Review Braz. J. Hea. Rev, Curitiba, v. 3, n. 6, p. 15803-15811, nov./dez. 2020. ISSN 2595-6825 15807 the aid in deambulation, the use of intravenous device, the type of gait and level of conscience. Each criterion evaluated receives a score ranging from zero to 30 points, being the total possible sum equal to 125. Of these, from zero to 24 points is considered low risk, from 25 to 44 points, intermediate risk and 45 or more points, high risk (BONARDI et al., 2019). For the evaluation of the risk of skin lesion caused by pressure, the Braden Scale, elaborated in 1987 by Braden and Bergstron, is used, analyzed through six parameters: sensorial perception, humidity, mobility, activity, nutrition, friction and shear. The first five parameters receive scores from one to four, while the last can be evaluated from one to three. In this case a low score points to a higher risk of pressure injury (SOUSA JÚNIOR et al., 2017). The Fugulin Scale, on the other hand, verifies the degree of dependence of the patient during hospitalization, establishing nine areas of care, being them: level of consciousness, oxygenation, vital signs, motility, walking, feeding, body care, elimination and therapy. According to the obtained scores, the patients are categorized in minimum care, from nine to 14 points; intermediate, from fifteen to twenty points; high dependence, from 21 to 26 points; semi-intensive, from 27 to 31 points; and intensive care, above 31 points (BRANDAO et al., 2017). In this way, the register in electronic record allows the visualization of the multiprofessional clinical evolutions, laboratory and image examinations, and the development of prescriptions of nursing and doctor. The search for patient data occurs through the use of a system called Medview in which it is possible to share and follow up information in a detailed way about the history and evolution of the patient. All this technology in health provides the ease, security and agility of access, being indispensable for multiprofessional team communication, and especially for the quality of care provided to the patient by offering an integrated care, with clarity of information and confidentiality of data. However, the implementation of this tool requires the training and commitment of the professionals involved in the process, in search of holistic and patient-centered care. CONCLUSION: As a technology employed in health care, this tool brings innovation in the field of hospital care, allowing the visibility of the information needed for full patient care. It is recommended that institutions employ in a correct and effective way the use of PEP, through training with the health team, providing adequate physical resources, and also encouraging the development of future research.

brazilian journal of health review

O uso do prontuário eletrônico como ferramenta no exercício da Enfermagem: relato de experiência / The use of the electronic record as a tool in the exercise of nursing: experience report