Revista Gestão & Saúde (Sep 2013)
OCCURRENCE OF FAULT RECORDS OF NURSING CARE IN A HOSPITAL MEDICAL UNIT
Abstract
The nursing records have value as a procedural document, source of inquiry and teaching tool. It is worth mentioning that, the records are actions performed through care processes, generating revenue for the institutions.The objective of this study was to identify the major record failures of nursing care. The survey was conducted in an Adult Clinic of a private hospital in Caxias do Sul, in the period of March to April, 2012. Data were collected through the reporting of the auditorship service and through the application of a questionnaire to the nursing staff. The main problems found were the lack of scheduling, checks and nursing records, the incorrect materials and drugs request by nursing, mistakes in prescriptions and imcomplete forms. From the problems identified it is suggested the intensification of continuing education on nursing records and further studies to identify the economic value lost by glosses in hospital bills.
