Diseño de un programa de auditoría para evaluar el cumplimiento documental del estándar de procesos prioritarios establecido en la Resolución 3100 de 2019 en el Grupo Internación/Servicio de Hospitalización de la ESE Hospital Local San Pablo

Abstract

Documentary compliance with health service licensing standards is an important component of the organization, traceability, and continuous improvement of healthcare services. The objective of this study was to design an audit program to evaluate documentary compliance with the Priority Processes Standard established in Resolution 3100 of 2019 in the Inpatient Group/Hospitalization Service of the ESE Hospital Local San Pablo. An applied, descriptive, mixed-methods study was conducted in three phases. In the first phase, the applicable regulatory criteria were identified and classified. In the second phase, the audit program was designed and the checklist was applied in a controlled manner to verify its functionality and obtain documentary compliance results. In the third phase, improvement strategies were proposed based on the identified gaps. A total of 50 regulatory criteria were identified and organized into 68 assessment items. Of the 55 applicable items, 54 were compliant and one was non-compliant, resulting in a documentary compliance rate of 98.18%. The identified deviation corresponded to regulatory criterion 42.7, related to the institutional nursing care plan form. The audit program provides a systematic tool for documentary verification, identification of gaps, and development of improvement actions. However, its results do not represent a comprehensive certification of compliance with health service licensing requirements or an assessment of clinical practice.