AUDITING THE QUALITY OF NURSING CARE THROUGH HOSPITAL RECORDS

Abstract

The quality and completeness of nursing records are fundamental for traceability of care, patient safety, and care management. This study aimed to analyze the quality of nursing records in the medical records of patients hospitalized in a university hospital in Northeast Brazil, through a retrospective audit. This is a descriptive, cross-sectional, quantitative, and documentary study, carried out based on the audit of 151 medical records of patients hospitalized in 11 clinical-surgical units, between December 2022 and February 2023. Data collection was carried out between June 2024 and December 2025 by nurses from the Nursing Division, using a structured instrument. Data were analyzed using descriptive statistics and the McNemar test for paired comparison of record completeness between the first and fourth day of hospitalization. Low quality nursing notes were identified, classified as fair in 47.0% and poor in 46.4% of the medical records, as well as vital sign records, classified as fair in 60.9% and poor in 31.1%. Although nursing progress notes were present in 95.4% of the medical records, nursing diagnosis (9.9%), implementation (4.6%), and nursing evaluation (4.6%) were poorly documented, highlighting weaknesses in the continuity of the Nursing Process. The completeness of daily progress notes decreased from 74.2% on the first day to 46.4% on the fourth day of hospitalization (p < 0.001). Gaps were also observed in the application of risk scales, especially the Fugulin Scale, absent in 84.1% of the medical records, followed by the Morse (30.5%) and Braden (27.8%) scales. The findings reveal a pattern of documentary fragility that intensifies throughout hospitalization, compromising the traceability of care, patient safety, and support for decisions related to care and workforce sizing. Strengthening continuing education is recommended, especially during periods of higher risk of under-documentation, coupled with systematic monitoring of quality indicators through periodic audits. These measures can contribute to improving nursing documentation and supporting the management of care in hospital institutions.