Audit of medical records: evaluation of tracheal suction registers in intensive care unit

Abstract

It´s a descriptive and exploratory study with quantitative approach that had as objective the evaluation of the register of the procedure of tracheal suctioning in Intensive Care Unit by multiprofessional team using hospitalar auditing. The documentary analysis was used for evaluation of the register of the procedure. It was analised 21 medical records. The sample was composed by 37 registers of the Intensive Care Unit team. The research occurred in the period beteween January and May of 2006 in a public hospital in Rio de Janeiro. For data collection it had been used a check list instrument. To analise the register it was used as parameter a barema. It was observed that 89.6% of nursing staff and 100% of phisiotherapists staff register the procedure incompletely. The lack of register in 10,4% of analyzed nursing and in 100% of medicine medical record was verified. The data indicates that the register of the tracheal suction is defective in the unit in question. Measures of continued education and implementation of a protocol for these procedures are necessary and urgent.

Key words: Suction; Intensive Care Units; Nursing auditing; Medical records.