THE IMPORTANCE OF NURSING RECORDS IN HOSPITAL

Objective: to analyze the national scientific production on Nursing records and its direct relationship with hospital billing. Method: integrative review, performed in 20 articles available online, from 2006 to 2016, in the Medline, LILACS, BDEnf and SCIELO databases, analyzed through simple descriptive statistics, for the bibliometric analysis of the productions found, and Content Analysis, to deepen the relationship between Nursing records and hospital billing. Results: from this analysis the thematic categories "Hospital Environment and Nursing Registers"; "Audit of Nursing and Hospital Invoicing" and "The nurse professional in front of the audit sector" emerged. Conclusion: Nursing records express the quality of the care provided to the patient, have repercussions on the billing of the hospital bill, guide the management in the monitoring of quality indicators and enable the financial maintenance of the health service. It is important to emphasize the importance of continuing education about Nursing records and its interface with the financial health of the health organization. Descriptors: Nursing Audit; Billing; Quality of Health Care; Nursing professionals; Nursing Records; Hospital economics. RESUMO Objetivo: analisar a produção científica nacional sobre os registros de Enfermagem e sua relação direta com o faturamento hospitalar. Método: revisão integrativa, realizada em 20 artigos disponíveis on-line, no período de 2006 a 2016, nas bases de dados Medline, LILACS, BDEnf e na biblioteca SCIELO, analisados por meio de estatística descritiva simples, para a análise bibliométrica das produções encontradas, e da Análise de Conteúdo, para o aprofundamento da relação dos registros de Enfermagem com o faturamento hospitalar. Resultados: desta análise, emergiram as categorias temáticas “Ambiente Hospitalar e os Registros de Enfermagem”; “Auditoria de Enfermagem e o Faturamento Hospitalar” e “O profissional enfermeiro frente ao setor de auditoria”. Conclusão: os registros de Enfermagem expressam a qualidade da assistência dispensada ao paciente, repercutem no faturamento da conta hospitalar, balizam a gestão no acompanhamento de indicadores de qualidade e viabilizam a manutenção financeira do serviço de saúde. Ressalta-se a importância da educação permanente acerca dos registros de Enfermagem e sua interface com a saúde financeira da organização de saúde. Descritores: Auditoria de Enfermagem; Faturamento; Qualidade da Assistência à Saúde; Profissionais de Enfermagem; Registros de Enfermagem; Economia Hospitalar. RESUMEN Objetivo: analizar la producción científica nacional sobre los registros de Enfermería y su relación directa como el facturación hospitalaria. Método: revisión integrativa, realizada en 20 artículos disponibles en línea, en el período de 2006 a 2016, en las bases de datos Medline, LILACS, BDEnf y en la biblioteca SCIELO, y analizados por medio de estadística descriptiva simple, para el análisis bibliométrico de las producciones encontradas, y de la Análisis de Contenido para la profundización la relación de los registros de Enfermería como la facturación hospitalaria. Resultados: de este análisis, surgió las categorías temáticas: “Ambiente Hospitalario y los Registros de Enfermería”; “Auditoría de Enfermería y la Facturación Hospitalaria” y el “Profesional enfermero frente al sector de auditoría”. Conclusión: los registros de Enfermería expresan la calidad de la asistencia dispensada al paciente, repercute en la facturación de la cuenta hospitalaria, balizan la gestión en el seguimiento de indicadores de calidad y viabilizan el mantenimiento financiero del servicio de salud. Se resalta la importancia de la educación permanente acerca de los registros de Enfermería y su interfaz con la salud financiera de la organización de salud. Descriptores: Auditoría de Enfermería; Facturación; Calidad de la Atención de Salud; Profesionales de enfermería; Registros de Enfermería; Economía Hospitalaria. Nurse, Master's student in Biosciences and Health, Professor of the Nursing course at the State University of Santa Catarina / UDESC. Chapecó (SC), Brazil. E-mail: fabi_m2008@hotmail.com ORCID: http://orcid.org/0000-0003-1178-2637; Nurse, PhD in Nursing, Professor of the Nursing course at the State University of Santa Catarina / UDESC. Chapecó (SC), Brazil. E-mail: rosana.ascari@hotmail.com ORCID: http://orcid.org/0000-0002-2281-8642; Nurse, University of the State of Santa Catarina / UDESC. Chapecó (SC), Brazil. E-mail: mairaacassia@gmail.com ORCID: http://orcid/0000-0002-6077-9250 INTEGRATIVE REVIEW ARTICLE Pertille F, Ascari RA, Oliveira MCB de. The importance of nursing records in... English/Portuguese J Nurs UFPE online., Recife, 12(6):1717-26, June., 2018 1718 ISSN: 1981-8963 https://doi.org/10.5205/1981-8963-v12i6a234419p1717-1726-2018 The health scenario is constantly changing and some factors are determinant for the entities that offer health services. New epidemiological features, the improvement of diagnostic medicine, high complexity treatments, the growth of the pharmaceutical industry, the multiplicity of health agreements and national health policies are some factors that are related to the current scenario and are closely related to the quality of services provided. The need to control finances, monitor costs, and measure quality and customer satisfaction becomes the unit's greatest concern. As a tool to control the process, the audit has been effective and resolutive evaluating the service provided, measuring costs and expenses and monitoring the records. The work of the Nursing team is directly related to the audit service, contributing to the measurement of audited items, glosses and financial return. The main instrument used by the audit service is based on Nursing care and the records produced by it in the patient's medical records, since the patient's stay in the hospital is recorded in the patient's medical records containing all the activities, intercurrences and procedures performed with the patient. The Nursing team, by specifying their work, is involved in all stages of patient care and represents the most significant number of records related to medical and Nursing procedures, examinations, medications, evaluations, intercurrences, expense records and everything else that could be related to the therapeutics used, being responsible for the main data that support the results of the audit. Audit findings about Nursing records provide information about the quality of care provided to the patient / family, the need for staff training in protocol development, cost control, waste avoidance strategies, care indicators, and data statistics on financial turnover and hospital billing. An analysis of the recent literature has shown that the lack of capacity building, the great care demands in the hospital area and the precariousness of the Nursing work directly affect the care costs and influence the quality of the Nursing records. In this context, the question is: How do Nursing records contribute to improving hospital billing? It is believed that the nonconformities in the Nursing records are common and stem from the mistaken perception of Nursing professionals that registration is not a priority in the face of the great population demand for health services, where professionals sometimes opt for care to the detriment of records. In this sense, the literature indicates the responsibility of the professionals for the correct fulfillment of the patient's medical records and their impact on the quality of care due to Nursing records. ● To analyze the national scientific production on Nursing records and their direct relationship with hospital billing. It is an integrative literature review that allows the construction of a broad analysis of the chosen literature in order to respond to the stated objectives. The preparation of this review was done through pre-defined stages, namely: identification of the theme and research question; application of the inclusion and exclusion criteria; definition of the information to be extracted from the studies; analysis of included studies; interpretation and presentation of results. The selection of the articles was done in the following databases: Medical Literature Analysis and Retrieval System Online (Medline), Latin American Literature in Health Sciences (LILACS), Nursing Database (BDENF) and Scientific Eletronic Library Library Online (SCIELO). The health terminologies used were selected from the Health Sciences Descriptors (DeCS) and the Medical Subject Headings (MeSH) represented by "Nursing Audit", "Nursing Registers", "Quality of Health Care", "Supervision of Nursing "and used in the search of articles in combination with the Boolean operator" AND "to refine the studies that addressed only the selected theme. There inclusion criteria considered were those published between January 2006 and December 2016; available in Portuguese; national publications; in the form of the scientific article (experience reports, integrative literature reviews, original articles); available online in complete copy, free of charge; which deal with Nursing records and their relation with hospital billing. The exclusion criteria were based on the works of conclusion of course, monographs, theses and dissertations; duplicate articles; publication format such as book / book OBJECTIVE