Electronic Health Record (EHR) is currently the most secure method for recording clinical information during hospitalization. This study aimed to analyze and describe the use of physical medical records and the transition in the implementation of EHR tools. It is an observational and interventional study conducted in a high-complexity hospital in the city of Coroatá, in the interior of Maranhão. The unit’s workflows were observed, where records were made manually from admission to discharge. The Klinikos and GMed system was adopted as the EHR implementation. Sectors without computers with internet access and professionals who did not adapt to the implementations did not achieve the study’s objective. The reception and inpatient sectors were observed, of which only the two Adult Intensive Care Units and the Medical Clinic were able to fully implement the available tools. The surgical clinics faced difficulties in implementation due to the professionals’ lack of familiarity with the system and technologies for non-young professionals. Additionally, a lack of equipment for EHR implementation was observed in these sectors. The implementation of the EHR demonstrated increased agility in care delivery and the security of electronic storage and accessibility of documents, such as medical prescriptions. For a complete implementation in the unit, it is necessary to invest in staff training and the acquisition of equipment for the deficient sectors.