Auditoria de custo: análise comparativa das evidências de glosas em prontuário hospitalar

Resumo (EN)

Introduction – The auditorship of costs has achieved a fundamental space at the hospital institutions, due to market competition and customers requirements, being therefore necessary to the qualification of health care service. The quality of multi-disciplinary assistance and the variances of information found on the records are relevant, as well as the financial loss and the worthiness decrease on health care services provided by institutions. This study aims to evaluate the most frequente indicators on hospital discussions, through the evaluation of hospital records and the nursing annotations for a general reduction of these rates. Material and Methods – This paper is a descriptive research, retrospective analysis in hospital records not audited in a philanthropic hospital institution and accredited by several health care operators within the interior of the State of São Paulo. Concerning to the collection of data two instruments have been used, one for the characterization of the records designed by the proper research, and another draw out from the scientific literature to the assessment of the quality of nursing annotations. The collection of data was accomplished in July 2007, adding up a sample of sixty records in total. A descriptive analysis in view of the characterization of the records, the disagreement in relation to nursing annotation and a comparative analysis using were accomplished. Results –The outcomes showed inconsistency, incoherence, little scientific use among the prescription and clinical evolution, annotation and nursing check, Conclusions – It makes evident the part of the nurse auditor, indicates the variances and guide the correct way, brings subsidy for continued education and promotes an effective multidisciplinar job.