Importance of the nursing register to avoid the gloss in the audit: an integrative review

uma revisão integrativa

Abstract

Abstract: Public and private institutions have invested constantly in auditing costs, comparing whether the services provided are similar to those charged during auditing. The aim of the review was to identify the scientific production that they discuss about the reasons of inaccurate records of the nursing team in the charts that cause the gloss in the nursing audits. In this context, the importance of the nursing team related to health care is inserted. It is an Integrative Review about the reasons for imprecise records of the nursing team in the charts that cause the gloss in the nursing audits. The studies were identified through electronic search in the database of the Virtual Health Library (VHL), Latin American and Caribbean Literature in Health Sciences (LILACS) and Scientific Eletronic Library Online (SCIELO), from February to April 2019. A total of 146 articles were identified for reading the abstract and / or full text, 136 were excluded because they did not fit the eligibility criteria, 10 studies were included. It was possible to observe in the included studies the focus on strategic planning / management allied to education as essential to avoid glosses, being the continuing education not only of the nursing team as well as managers in the hospital scope in order to reduce errors and costings with regard to expenses related to health. In addition to management planning, the work of the professional nurse and his team was the focus of several papers in this review citing the importance in nursing notes, as well as the management of care that influences not only the issue of glosses, but also the patient care properly. The main misconceptions in the nursing records that lead to the billing glossary by the nursing audit in medical records derive from the deficiency in the management / planning of the managers and in the lack of educational activities, however, future studies with greater comprehensiveness and methodological quality are needed to better elucidate this theme.