VALIDATION &

DOCUMENTATION
of DATA
 Learning Objectives

At the end of this lesson, students should be able

to:
1. Provide with a comprehensive understanding of
the Good Documentation Practices
2. Establish objective evidence for activities
performed or results achieved (Records).
3. Learn the basic writing skills, and step-by-
step description of how to write SOPs and
policy in an informative manner.
 VALIDATION of DATA

VALIDATING DATA
Double checking or verifying the data
whether it is factual or accurate

The assessment information of Nursing

diagnosis and interventions must be
accurate, factual and complete.
 Purposes of data
validation:
– ensure that data collection is
complete
– ensure that objective and subjective
data agree
– obtain additional data that may
have been overlooked
– avoid jumping to conclusion
– differentiate cues and inferences
 Data Requiring Validation
Conditions that require data to be rechecked and
validated includes:
– Discrepancies or gaps between the subjective
and objective data.
– Discrepancies or gaps between what the client
says at one time and then another time.
– Findings those are very abnormal and
inconsistent with other findings.
N.B. Not every piece of data you collect must be verified. For example:
you would not need to verify or repeat the client’s pulse, temperature,
or blood pressure unless certain conditions exist.
 Methods of Validation

– Recheck your own data through a repeat

assessment.
– Clarify data with the client by asking
additional questions.
– Verify the data with another health care
professional.
– Compare you objective findings with your
subjective findings to uncover discrepancies.
 DOCUMENTATION
of DATA

Guidelines for Documentation

– Written notes
– Electronic documentation
 DOCUMENTING DATA

– Accurate documentation is essential

which include all data collected about
client’s health status.
– Record in a FACTUAL manner NOT
interpretation

e.g. Recording the breakfast intake as –

ate 2 pieces of Bread toast, 1 egg and a
cup of coffee instead of “Good appetite”
 Guidelines
for Documentation
– Record the client’s understanding and perception
of problems
– Avoid recording the word “normal” for normal
findings
– Record complete information and details for all
client symptoms or experiences
– Include additional assessment content when
applicable
– Support objective data with specific observations
obtained during the physical examination
 PURPOSES
OF DOCUMENTATION

– Communication
– Practice and legal standards
– Reimbursement
– Education
– Research
– Nursing audit
 REIMBURSEMENT

The federal government requires

monitoring and evaluation of quality,
appropriateness of care provided.
– Documentation of intensity of services
and severity of illness reviewed.
– Failure to document can result in
reimbursement denied.
 EDUCATION

– Health care students use medical record

as tool to learn about disease processes,
nursing diagnoses, complications and
interventions.
– Students can enhance critical-thinking
skills by examining the records and
following health care team’s plan of care.
 RESEARCH

– The client’s medical record is used by

researchers to determine whether a
client meets the research criteria for a
study.

– Documentation can also indicate a

need for research.
 NURSING AUDIT
Method of evaluating the quality of care
Includes:
- Safety measures
- Treatment interventions and responses
- Expected outcomes
- Client teaching
- Discharge planning
- Adequate staffing
 Safe Documentation
– Follow hospital/agency policy
– Failure to follow policy can result inconsistencies
and appear non-credible in a court of law.
– Follow policies in how to make late entries
– Patients name is on every page
– Date and time of entry
– Chronology of events
– Maintain objectivity and not opinions
– Everything must be legible
– You signature and credentials
 PRINCIPLES OF EFFECTIVE
DOCUMENTATION
– Document accurately,
completely, and objectively,
including any errors – Spell correctly
– Note date and time – Write legibly
– Use appropriate forms – Correct errors properly
– Identify the client – Write on every line
– Write in ink – Chart omissions
– Use standard abbreviations – Sign each entry
 SYSTEMS OF
DOCUMENTATION

- Narrative charting
- Source-oriented charting
- Problem-oriented charting
- PIE charting
- Focus charting
- Charting by exception
- Computerized documentation
- Critical pathways
 NARRATIVE CHARTING

– Traditional method of nursing

documentation
– Chronologic account in paragraphs
describing client status,
interventions and treatments, and
client’s response
– The most flexible system
– Usable in any clinical setting
 Sample

Narrative Format
Progress Recordings
January 22, 2022 5th Tamayo Tower 8:30 AM Daily Note

Patient talking to unseen stimuli since beginning of shift. Became increasingly loud and
argumentative with the staff. Doctor having rounds- medication revised. Received a p.r.n.
medication at 12PM. Refused his lunch and continued to respond to unseen stimuli the
remainder of the shift.
Precy P. Lantin, RN, MAN
Lic # 12345678
 SOURCE-ORIENTED
CHARTING

– Narrative recording by
each member of the health
care team on separate
documents
 Sample
Date Time Notes
01/26/22 0700 Pt 4hrs post op: awakens easily: oriented x 3 but groggy.
Incision site in LLQ, 5cm, without dressing, no bleeding,
sutures intact. Pt denied pain but stated she felt
nauseated and promptly vomited 100ml of clear fluid. Pt
attempted to get OOB to ambulate to the bathroom with
assistance but felt dizzy upon standing. Assisted to lie
down in bed. Voided 200ml clear, yellow urine in
bedpan----------------------------------------Precy Lantin, RN,MAN
01/26/22 0730 Pt. continues to feel nauseated. Metoclopramide 10mg
TIV given as ordered. -------------------Precy Lantin, RN,MAN
01/26/22 0830 Pt. states she is no longer nauseated, remains pain free.
No further vomiting.--------------------Precy Lantin, RN,MAN
 PROBLEM-ORIENTED
CHARTING
SOAP, SOAPI, AND SOAPIER
S: subjective data
O: objective data
A: assessment data
P: plan
I: implementation
E: evaluation
R: revision
Sample

Precy P. Lantin, RN, MAN

Lic # 12345678
 PIE CHARTING
PIE CHARTING
P:problem
I: intervention
E:evaluation
 FOCUS CHARTING
Focus - This is the subject/purpose for the note. The
focus can be: Nursing diagnosis, Event (admission,
transfer, discharge teaching etc.), Patient Event or
Concern (code blue, vomiting, coughing).
Data - subjective & objective patient assessment data
that supports the Focus Statement or describes
observations of a significant event
Action - immediate or future actions or plans of action or
care based on the evaluation of assessment data
Response - the patient response to the action taken.
 Sample
FOCUS CHARTING
– System using a column format to
chart Data, Action, and Response
(DAR).
.
 CHARTING BY EXCEPTION

– Only significant findings (exceptions)

are documented in a narrative form.
– Presumes that unless documented
otherwise, all standardized protocols
have been met and no further
documentation is needed.
 COMPUTERIZED
DOCUMENTATION
COMPUTERIZED DOCUMENTATION

– Reduces time taken, increases accuracy

– Increases legibility
– Stores, retrieves information quickly
– Improves communication among health care
department
– Confidentiality and costs can be problems
 CRITICAL PATHWAY

CRITICAL PATHWAY
– Also known as Care Maps.
– Comprehensive pre-printed standard plan
reflecting ideal course of treatment for
diagnosis or procedure, especially with
relatively predictable outcomes.
– Additional forms are needed to
complement the pathway.
REFERENCES

Dillon, P.M. (2015). Nursing Health Assessment A

CRITICAL THINKING, CASE STUDIES
APPROACH. 2nd edition. F. A. Davis Company,
Philadelphia, PA 19103

Weber, Janet R (2017). Health Assessment in

Nursing, 6th Edition. Lippincott Williams &
Wilkins