Follow-up of the audit in the implementation of the checklist at the medical records conference in a philanthropic institution

Abstract

The patient's record must be unique for everyone in each hospital, gathering records of outpatient, emergency, and hospitalization. The purpose of this article was to verify the importance of correct and complete filling of the patient's medical record during the assistance provided to the client and to identify the effectiveness in the implementation of the checklist for checking medical records in relation to the improvement of processes and the financial impact of the Institution. The field research was carried out through the sampling of 100 random medical records, 50 of which were medical records without the use of the checklist in the medical records conference and 50 medical records with the use of the checklist in the medical records conference. Data were collected through the audit performed by the Nurse Auditor in the medical records, after being analyzed to achieve the objectives. It is concluded that the change provided a continuous improvement of processes and the financial impact related to the agility in billing hospital bills.