BVS CLAP/SMR-OPS/OMS

The United Nations Millennium Development Goals pose a significant challenge concerning monitoring of indicators for the sexual and reproductive health-related goals. Information systems should aim at facilitating meeting those commitments, while guaranteeing the quality of the care provided. This quality of care is based on the organization of the departments and an adequate data system that should include an appropriate Clinical Record. Furthermore, the flow of information should ensure the availability of any data required for the correct management of a patient to the health care professional in charge of the patient in question. The Clinical Record must facilitate care, monitoring and supervision of compliance with standards, to provide the health system with precise and timely data for decision making. The wealth of data in the Perinatal Clinical Record pools the most valuable data bank and makes it available to the health team. That information may be used either to learn about the characteristics of the population receiving care or to evaluate the outcomes of the care provided, to identify priority issues, to monitor key indicators and to conduct operational and epidemiological research. The Perinatal Electronic System (PES) developed by CLAP/SMR in 1983 includes software to collect and analyze the clinical information built into the health care process in the various levels of complexity; it consists of the Perinatal Clinical Record (PCR) the delivery-gram, the Perinatal Card (PC) and the software for personal computers. This handbook gives a detailed description of the way the Perinatal Clinical Record should be filled, as well as the definition and interpretation of each of its variables.