Nursing audit: The impact of nursing annotation in the context of hospital gloss

Abstract

This study is based on our observation of the effect nursing records can have on hospital audits. The question motivating the research is: How can the professional nurse’s records help to avoid audits? The objective is twofold: to identify the effect of not having nursing records that can avoid eventual audits, and to show the primary results of having nursing records. This is a descriptive, exploratory study of a qualitative-quantitative nature. It was developed in documentary form at the urology unit of a private hospital in the town of Niteroi in Rio de Janeiro. The data was collected and examined from an exploratory, selective, analytical and interpretive standpoint. A thematic analysis made it possible to construct tables and graphs of audits involving medication (53%), taxes and rentals (24%), and materials (23%). The study demonstrates the value of nursing records in reducing hospital audits. For that reason, the nursing team must be made aware of the responsibility and commitment involved in keeping complete and appropriate hospital medical records.