AUDITORIA EM ENFERMAGEM: revisão dos prontuários de pacientes internados pelo Sistema Único de Saúde (SUS) em um Hospital de pequeno porte no sul de Minas Gerais

Abstract

ln this paper we present a documentary retrospective study of statistical nature in arder to examine the question of the quality of hospital records and knowledge on the part of the nursing team, when it comes to respectfor their fill and Obligations. Data coflection was based on the analysis of ali medical records of patients admitted by the Unified Health System (SUS) of the montli March 2015 in a small hospital in southern Minas Gerais, based on a docurnentary researcn script and literature in the form of check list, following pre-established criteria such as: P (has) NP (not have), C (complete), I (incomplete), NPR (not filled), prepared by the Systern Manual Üperating Technician Hospital Information of the Ministry of Health in 201 O, institutional protocols and specific scientific literature of nursing. Such research aimed to analyze and evaluate the quality of hospital records, which guides us to lhe nursing process of completion, developrnent and review of the sarne in the chosen institution. ln response to this situation, it is expected that the present study show the professionals involved the importance of adequate filling of hospital records, and disabled professional, motivated and lack of training in lhe specific area, are reasons for possible failures, which can generate glosses in the generated accounts, reduced hospital revenues, deficit ln provided quality and illegality according to the rufes and Laws which govern lhe profession. The results showed that that general filler items required in hospital records are being respected according to the individual knowledge of each member of the nursing staff, ar through instructions received by lhe sarne verbally, that is, the team did not is guided in any systematizaiion of nursing care, as this is not carried out in the institution. Therefore, it can be concluded that with the implementaüon of SAE and an aclive internai nursing audit service, assistance would present a quality increase consecutively greater acceptability and reliabitity by patients, and increased the monthly billing agreement with hospital ceiling previously established by SUS.