Steps of Health Assessment

Part 2
STEPS OF HEALTH ASSESSMENT

• Collection of subjective data

• Collection of objective data
• Validation of data
• Documentation of data
1.Collection of subjective data
• Sensations or symptoms • Beliefs
• Feelings • Ideas
• Perceptions • Values
• Desires • Personal information
• Preferences
Major areas of subjective data
• Biographical information
• Physical symptoms related to body parts
• Past health history
• Family history
• Health and lifestyle practices
2.Collection of objective data
Directly observed by the examiner
Include:
• Physical characteristics
• Body functions
• Appearance
• Behavior
• Measurements
• Results of laboratory testing
3. Validating assessment data
• Ensure all relevant data have been collected
• Prevent documentation of inaccurate data
Validating data

• Process of confirming or verifying that the subjective and

objective data you have collected are reliable and accurate
 Steps of validation
• Deciding whether data requires validation
• Determining ways to validate data
• Identifying areas where data are missing
 Data requiring validation
• Discrepancies or gaps between the subjective and objective data
• Discrepancies or gaps between what the client say at one time then
at another time
• Findings that are very abnormal or inconsistent with other findings
 Methods of validation

• Recheck your own data

• Clarify data by asking additional questions
• Verify data with another health care professional
• Compare your objective findings with your subjective findings to uncover
discrepancies
4. Documenting data
 Purposes of documentation
• Primary reason is to provide data base
• Provides source of client assessment data
• Ensures information about the client and family is easily accessible among
health team members
• Helps identify health problems and formulate nursing diagnosis and
information
• Determines educational needs of clients, family and significant others
 Purposes of documentation

• Provides basis for eligibility to reimbursements

• Constitutes a permanent legal record
• May be used for future investigations and research
 TYPES OF documentation

❑Written Notes
❑Electronic Documentation
 GUIDELINES FOR DOCUMENTATION

• Ensure that you have the correct client record or chart and that the client’s
name and identifying information are on every page of the record
• Document as soon as the client encounter is concluded to ensure accurate
recall of data
• Date and time each entry
• Sign each entry with your full legal and with your professional credentials
• Do not leave space between entries
• If an error is made, use a single line to cross out the error, then date, time
and sign the correction
• Never change another person’s entry, even if it is incorrect
• Use quotation marks to indicate client responses
• Document in chronological order
• Write legibly
• Use a permanent-ink pen
• Document in a complete but concise manner by using phrases and
abbreviations
• Document all telephone calls that you make or receive related to a client’s
case