Nursing annotations as an essential tool for hospital audit: bibliographical review
| Autor(a) principal: | |
|---|---|
| Data de Publicação: | 2019 |
| Outros Autores: | , , , |
| Tipo de documento: | Artigo |
| Idioma: | por |
| Título da fonte: | Research, Society and Development |
| Texto Completo: | https://rsdjournal.org/index.php/rsd/article/view/1060 |
Resumo: | The present article reports the influence of the annotations made by the nursing team in the medical records, passing through the hospital audit, in order to improve patient care. This is a bibliographical review, based on the collection of digital magazines, books, ordinances and government websites, bringing information about the concept of hospital audit, Auditor and a brief history on the implementation of these terms and professions in the health area. It is concluded that it is extremely important to raise awareness and motivation of nursing when filling in the progress sheets and medical records, trying to minimize communication or understanding failures about medical records, making it essential to perform the audit, correlating the correct annotations of the records to the quality of the nursing care. |
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Nursing annotations as an essential tool for hospital audit: bibliographical reviewAnotaciones de enfermeira como herramienta essencial para auditoria hospitalaria: revisión bibliográficaAnotações de enfermagem como ferramenta essencial para auditoria hospitalar: revisão bibliográficaAuditoría de EnfermeríaGestión HospitalariaCalidad AsistencialSaludLos registros médicos.Auditoria de EnfermagemGestão HospitalarQualidade AssistencialSaúdeProntuários.Nursing AuditHospital ManagementQuality AssuranceCheersRecords.The present article reports the influence of the annotations made by the nursing team in the medical records, passing through the hospital audit, in order to improve patient care. This is a bibliographical review, based on the collection of digital magazines, books, ordinances and government websites, bringing information about the concept of hospital audit, Auditor and a brief history on the implementation of these terms and professions in the health area. It is concluded that it is extremely important to raise awareness and motivation of nursing when filling in the progress sheets and medical records, trying to minimize communication or understanding failures about medical records, making it essential to perform the audit, correlating the correct annotations of the records to the quality of the nursing care.El presente artículo relata la influencia de las anotaciones realizadas por el equipo de enfermería en los prontuarios médicos, pasando por la auditoría hospitalaria, a fin de mejoras en la atención a los pacientes. Se trata de una revisión bibliográfica, basada en el acervo de revistas digitales, en libros, porteros y sitios gubernamentales, trayendo informaciones sobre el concepto de auditoría hospitalaria, Enfermero Auditor y un breve histórico sobre la implantación de esos términos y profesiones en el área de la salud. Se concluye que es de extrema importancia la concientización y motivación de la enfermería en el momento de llenar las fichas de evolución y prontuarios, atentándose para minimizar las fallas de comunicación o de entendimiento acerca de los prontuarios, haciéndose esencial la actuación de la auditoría, correlacionando las anotaciones correctas de los registros a la calidad del cuidado de enfermería.O presente artigo relata a influência das anotações realizadas pela equipe de enfermagem nos prontuários médicos, perpassando pela auditoria hospitalar, afim de melhorias no atendimento aos pacientes. Trata-se de uma revisão bibliográfica, baseada no acervo de revistas digitais, em livros, portarias e sites governamentais, trazendo informações sobre o conceito de auditoria hospitalar, Enfermeiro Auditor e um breve histórico sobre a implantação desses termos e profissões na área da saúde. Conclui-se que é de extrema importância a conscientização e motivação da enfermagem no momento de preencher as fichas de evolução e prontuários, atentando-se para minimizar as falhas de comunicação ou de entendimento acerca dos prontuários, fazendo-se essencial a atuação da auditoria, correlacionando as anotações corretas dos registros à qualidade do cuidado de enfermagem.Research, Society and Development2019-03-29info:eu-repo/semantics/articleinfo:eu-repo/semantics/publishedVersionapplication/pdfhttps://rsdjournal.org/index.php/rsd/article/view/106010.33448/rsd-v8i6.1060Research, Society and Development; Vol. 8 No. 6; e28861060Research, Society and Development; Vol. 8 Núm. 6; e28861060Research, Society and Development; v. 8 n. 6; e288610602525-3409reponame:Research, Society and Developmentinstname:Universidade Federal de Itajubá (UNIFEI)instacron:UNIFEIporhttps://rsdjournal.org/index.php/rsd/article/view/1060/885Copyright (c) 2019 Tatiana Carla Carvalho Amorim Guisande, Victor Hugo Martinsinfo:eu-repo/semantics/openAccessGuisande, Tatiana Carla Carvalho AmorimMartins, Victor Hugo da SilvaGuisande, Maria Thereza Carvalho RodriguezBezerra, Nadyr CristinaTavares, Venâncio de Sant'ana2020-03-25T16:07:00Zoai:ojs.pkp.sfu.ca:article/1060Revistahttps://rsdjournal.org/index.php/rsd/indexPUBhttps://rsdjournal.org/index.php/rsd/oairsd.articles@gmail.com2525-34092525-3409opendoar:2024-01-17T09:26:15.086682Research, Society and Development - Universidade Federal de Itajubá (UNIFEI)false |
| dc.title.none.fl_str_mv |
Nursing annotations as an essential tool for hospital audit: bibliographical review Anotaciones de enfermeira como herramienta essencial para auditoria hospitalaria: revisión bibliográfica Anotações de enfermagem como ferramenta essencial para auditoria hospitalar: revisão bibliográfica |
| title |
Nursing annotations as an essential tool for hospital audit: bibliographical review |
| spellingShingle |
Nursing annotations as an essential tool for hospital audit: bibliographical review Guisande, Tatiana Carla Carvalho Amorim Auditoría de Enfermería Gestión Hospitalaria Calidad Asistencial Salud Los registros médicos. Auditoria de Enfermagem Gestão Hospitalar Qualidade Assistencial Saúde Prontuários. Nursing Audit Hospital Management Quality Assurance Cheers Records. |
| title_short |
Nursing annotations as an essential tool for hospital audit: bibliographical review |
| title_full |
Nursing annotations as an essential tool for hospital audit: bibliographical review |
| title_fullStr |
Nursing annotations as an essential tool for hospital audit: bibliographical review |
| title_full_unstemmed |
Nursing annotations as an essential tool for hospital audit: bibliographical review |
| title_sort |
Nursing annotations as an essential tool for hospital audit: bibliographical review |
| author |
Guisande, Tatiana Carla Carvalho Amorim |
| author_facet |
Guisande, Tatiana Carla Carvalho Amorim Martins, Victor Hugo da Silva Guisande, Maria Thereza Carvalho Rodriguez Bezerra, Nadyr Cristina Tavares, Venâncio de Sant'ana |
| author_role |
author |
| author2 |
Martins, Victor Hugo da Silva Guisande, Maria Thereza Carvalho Rodriguez Bezerra, Nadyr Cristina Tavares, Venâncio de Sant'ana |
| author2_role |
author author author author |
| dc.contributor.author.fl_str_mv |
Guisande, Tatiana Carla Carvalho Amorim Martins, Victor Hugo da Silva Guisande, Maria Thereza Carvalho Rodriguez Bezerra, Nadyr Cristina Tavares, Venâncio de Sant'ana |
| dc.subject.por.fl_str_mv |
Auditoría de Enfermería Gestión Hospitalaria Calidad Asistencial Salud Los registros médicos. Auditoria de Enfermagem Gestão Hospitalar Qualidade Assistencial Saúde Prontuários. Nursing Audit Hospital Management Quality Assurance Cheers Records. |
| topic |
Auditoría de Enfermería Gestión Hospitalaria Calidad Asistencial Salud Los registros médicos. Auditoria de Enfermagem Gestão Hospitalar Qualidade Assistencial Saúde Prontuários. Nursing Audit Hospital Management Quality Assurance Cheers Records. |
| description |
The present article reports the influence of the annotations made by the nursing team in the medical records, passing through the hospital audit, in order to improve patient care. This is a bibliographical review, based on the collection of digital magazines, books, ordinances and government websites, bringing information about the concept of hospital audit, Auditor and a brief history on the implementation of these terms and professions in the health area. It is concluded that it is extremely important to raise awareness and motivation of nursing when filling in the progress sheets and medical records, trying to minimize communication or understanding failures about medical records, making it essential to perform the audit, correlating the correct annotations of the records to the quality of the nursing care. |
| publishDate |
2019 |
| dc.date.none.fl_str_mv |
2019-03-29 |
| dc.type.driver.fl_str_mv |
info:eu-repo/semantics/article info:eu-repo/semantics/publishedVersion |
| format |
article |
| status_str |
publishedVersion |
| dc.identifier.uri.fl_str_mv |
https://rsdjournal.org/index.php/rsd/article/view/1060 10.33448/rsd-v8i6.1060 |
| url |
https://rsdjournal.org/index.php/rsd/article/view/1060 |
| identifier_str_mv |
10.33448/rsd-v8i6.1060 |
| dc.language.iso.fl_str_mv |
por |
| language |
por |
| dc.relation.none.fl_str_mv |
https://rsdjournal.org/index.php/rsd/article/view/1060/885 |
| dc.rights.driver.fl_str_mv |
Copyright (c) 2019 Tatiana Carla Carvalho Amorim Guisande, Victor Hugo Martins info:eu-repo/semantics/openAccess |
| rights_invalid_str_mv |
Copyright (c) 2019 Tatiana Carla Carvalho Amorim Guisande, Victor Hugo Martins |
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openAccess |
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application/pdf |
| dc.publisher.none.fl_str_mv |
Research, Society and Development |
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Research, Society and Development |
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Research, Society and Development; Vol. 8 No. 6; e28861060 Research, Society and Development; Vol. 8 Núm. 6; e28861060 Research, Society and Development; v. 8 n. 6; e28861060 2525-3409 reponame:Research, Society and Development instname:Universidade Federal de Itajubá (UNIFEI) instacron:UNIFEI |
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Universidade Federal de Itajubá (UNIFEI) |
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UNIFEI |
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UNIFEI |
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Research, Society and Development |
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Research, Society and Development |
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Research, Society and Development - Universidade Federal de Itajubá (UNIFEI) |
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rsd.articles@gmail.com |
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1797052643336519680 |