A auditoria possibilita o desenvolvimento de indicadores de assistência, critérios de avaliação e conseqüente geração de novos conhecimentos. Objetivou-se avaliar a qualidade dos registros do exame físico na consulta de Enfermagem, no acompanhamento do crescimento e desenvolvimento infantil, mediante aplicação da auditoria nos prontuários. Estudo retrospectivo, de processo e documental, com abordagem quantitativa, realizado no Centro de Desenvolvimento Familiar (CEDEFAM), em novembro de 2007. Amostra composta por 146 prontuários abertos no ano de 2006, selecionados de forma casual simples. Foram analisados dados referentes à identificação do cliente e do profissional, estrutura do domicílio, presença de rasuras e exame físico. Os dados antropométricos, 80% preenchidos de forma completa, 15% de forma incompleta, 5% não preenchidos e 0% incorretas; todos os demais itens analisados ficaram abaixo destes percentuais. Concluiu-se ser necessário esclarecer os enfermeiros e acadêmicos quanto à importância do preenchimento adequado do prontuário, oferecendo alternativas para melhorar a qualidade dos registros.
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.
