Registros de enfermagem: pilar fundamental na auditoria de contas médicas

Abstract

This article aims to describe the relevance of nursing records in the analysis of medical billing during audits of the provided care. Nursing records ensure effective communication among professionals and continuity of care, as well as serving as support in audits and legal processes. This study is an integrative literature review that analyzed articles across three databases: LILACS (Latin American and Caribbean Health Sciences Literature), BDENF (Nursing Database), and SciELO (Scientific Electronic Library Online), using descriptors in Portuguese and English: Nursing Audit, Clinical Audit, Nursing Records, and Quality of Health Care. The results highlight that the quality of nursing records is crucial for the efficiency of hospital billing, as complete records prevent payment denials and ensure continuity of care. Additionally, the research emphasized that inadequate records compromise patient safety and the financial viability of healthcare institutions. The audit was identified as a vital tool for detecting non-compliances, promoting the improvement of care processes. It is concluded that nursing records are fundamental for the audit of medical billing, and when they are accurate and complete, they ensure continuity of care, minimize payment denials, and reinforce the financial sustainability of institutions. Nursing records play a decisive role in optimizing processes and legitimizing nursing practices, providing significant benefits for patients and healthcare organizations.