Characteristics of notes about nursery found in audit

• Autor(a) principal: Luz, Alessandra da
• Data de Publicação: 2009
• Outros Autores: Martins, Andreia Pereira, Dynewicz, Ana Maria
• Tipo de documento: Artigo
• Idioma: por
• Título da fonte: Revista Eletrônica de Enfermagem
• DOI: 10.5216/ree.v9i2.7165
• Texto Completo: https://revistas.ufg.br/fen/article/view/7165
• topic: Nursing Audit; Forms and records control; Medical Records.; Auditoria de Enfermería; Control de impresos y registros; Prontuarios.; Auditoria de Enfermagem; Controle de formulários e registros; Prontuários.

The objective of  the reserach was to identify the quality of  the registers of nusery in  hospitals bills, in three units of admission  of private health  plans, in a universsitary hospital, between august and november of 2005. The data was collected from nursey notes in 144 promptuaries, through a check list, elaborated according to the literature and legislation. The major  problems found are: notes made for shift and not for schedule; erasures and blank spares on the paper, the lack of stamp and signature. There were situations that  the checking of  the prescriptions weren’t  made or they or  they were done in na incorrect way. There were also incomplete notes of vital signs. Generally speaking, the notes were understanding, although the handwriting sometimes was not so legible. They used standard acronyms and technical terms. From the identified problems on it is suggested more intensification of the continued education about registers of the nursery and new studies that indentify the lost economic values, for gloss in hospital bills.