This study examines 34 procedure billing reports collected at health care facilities that participated in SIA-SIH/SUS activities in Rio Branco - Acre in 1994/1995. It aims at identifying and analyzing any errors found in the procedure notes. This study also used sub-categories which were defined through content similarity. A total of 491 errors were found in the procedure billing reports. This represents an average of 14.4% of errors per procedure billing report. When the procedure billing reports were analysed using 8 criteria, 198 (40.6%) administrative errors, 121 (24.6%) doctors errors, 99 (20.2%) nurses errors, and 51 (10.2%) accounting errors were detected. When the nurses' errors were further examined, it was detected that 34 (34.3%) were due to nurses notes and 15 (15.1%) as a result of erroneous medication administration. It was concluded that nursing staff is not following the standard note taking procedures. This places not only the patients at risk but also health care professionals and health care facilities which are responsible for patient care.
Nursing Auditorship; Nursing Records