Registros de enfermagem: impacto no processo da auditoria e faturamento

Abstract

The search for quality in health services and, in turn, the analysis of quality indicators comes to occupy spaces in the health and knowledge production niches, highlighting the nursing area and the audit service. Therefore, the general objective of this research was to analyze the nursing records, and how to define the criteria for identifying impact in the records of quality and billing audit processes, as well as verifying the number of glosses and their causes. This is a qualitative research and documentary approach carried out at a Hospital Institution of a municipality in the northwest region of Rio Grande do Sul. For the data collection used, the observation and systematic analysis of medical records of users who entered the service between September 2018 and January 2019. Inclusion criteria were promptly referenced in the Medical and Surgical Clinic and the exclusion criteria readily reserved for other sectors of the Hospital. Data analysis was performed through content analysis proposed by Bardin (2016). We analyzed 200 medical records, of these 46 had no records of the professional nurse, and there is no standardization of records. Another finding was the lack of the expense sheet for dressings in the medical records analyzed at the Surgical Clinic. Thus, it can be said that the identified techniques may be reflecting on the quality of care, as well as the audit and billing process.