Research Article
Volume 2 Issue 6 - 2020
Criteria Used in the Performance of Medical Records Audits: A Literature Review
Sayane Marlla Silva Milk* and Farias Daniel Lima
Leite Montenegro, Nurse, Federal University, Brazil
*Corresponding Author: Sayane Marlla Silva Milk, Leite Montenegro, Nurse, Federal University, Brazil.
Received: March 05, 2020; Published: May 06, 2020


Auditing is nothing more than a method used to systematically measure some action, whether in the health or business sphere, in the case of nursing records, the care recorded by the nursing team is audited, based on standards determined and stipulated by the class councils and hospital institutions. The study aimed to describe the criteria evaluated by auditing the nursing records in the patient’s medical records, in order to ensure the quality of the information that will be used by the entire health team of the institution. This is an integrative review of the literature, where consultations were made throughout the national literature (laws, decrees, articles) in relation to the theme auditing the records of patients, in order to describe the criteria used by auditors of hospital quality and internal audits regarding the registration of nursing care. It is concluded that the authors who are scholars of the theme of nursing records, conduct research without and focused on the analysis of medical records, determine the failures of records and are based on the legislation of the COFEN-CORENs system to discuss the findings of their studies and that they bring in their research criteria and concrete data for auditing records of entering.

Keywords: Nursing Audit; Nursing Record; Hospital Records


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  5. Brazil Laws and Decrees. “Law 5,869 of Establishes the Code of Civil Procedure”. Brasilia: Official Gazette of January 17, 1973 (1973).
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Citation: Sayane Marlla Silva Milk and Farias Daniel Lima. “Criteria Used in the Performance of Medical Records Audits: A Literature Review”. EC Nursing and Healthcare 2.6 (2020): 28-34.

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