Nursing audit: aspects of the quality of care and its registration in the medical record

Abstract

Objective: To analyze the nursing audit work process carried out in health institutions as a guarantee of the quality of the care provided and its adequate record in the patient's medical record. Method: Literature review, based on the selection of articles indexed in the databases of the Virtual Health Library and institutional evidence from the National Supplementary Health Agency and the Federal Nursing Council. Results and Discussion: From the foregoing, we could observe that the audit activities aim to: examine, measure, measure and observe whether the technical activities, operating systems and assistance protocols are being carried out within the required standards and recommended laws. Conclusion: It is evident, therefore, that if the health institution seeks to guarantee quality of care, financial sustainability, and safe records, it is necessary to establish a nursing audit team. In addition, we recommend more research that demonstrates the contribution of auditing in nursing degrees and at work in relation to risk management, aimed at patient safety.