Registration auditing in nursing consultation following infant growth and development

Abstract

Auditing makes possible the development of assistance indicators, evaluation criteria and, as a consequence, generation of new knowledge. The aim of this research was to evaluate the quality of registrations in physical examinations in nursing con­sultations during children development and growth accompaniment through auditing in Medical records. This is a retrospec­tive and documental study, quantitative approach accomplished at the Family Development Center (CEDEFAM), in November 2007. The sample was composed by 146 Medical records, open throughout the year 2006, selected at random. The data were analyzed regarding the customer and the professional’s identification, home structure, presence of deletions and physical exam registrations. As for the anthropometric data 80% were completely filled out; 15% were not completely filled out; 5% were not filled out at all and 0% was incorrect; all the remaining results were bellow these percentages. It was concluded that it is necessary to explain to the professionals and academics the importance of the appropriate Medical records completion offering alternatives to improve the quality of the registers.