Impacto da descrição de materiais pela enfermagem nas glosas durante a auditoria

Abstract

Abstract

Auditing is a tool used by health services to improve processes, enhance the appropriate use of available resources and achieve expected results. It is used in a way that controls the use of financial resources and the provision of health services, aimed at controlling costs, ensuring the quality of health care in the public and private sector. Nursing professionals are directly involved in this process, and work to ensure that the documents used are completed appropriately, the main one being the nursing note in the patient's medical record. The objective of this work is to guide the nursing team to carry out an elaborate description of the materials used and procedures carried out during nursing care for patients, during the hospitalization period, with the purpose of avoiding glosses in the audit processes. This is a literary review, in which data collection occurred to describe the problem indicated in the objective. Much of the payment for materials, medicines, procedures and other services is related to the records made by the nursing team in medical records. The lack of registration can be interpreted as the procedure not being carried out, for example, financially affecting the health service that provided assistance to the patient, who may not receive payment for the service provided due to the absence of these records in the medical record. It is important that health institutions invest in ongoing education for nursing professionals related to nursing notes and records in the patient's medical record, informing the importance of nursing notes with complete information inherent to the care provided, with quality records, to avoid disallowances of hospital bills and reduce the institutions' financial losses, in addition to guaranteeing the institution the quality of care and secure information for cost management.

Keywords: glosses; nursing notes; audit; nursing records, internal audit, external audit, hospital audit, continuing education.