Chapter 5

Validating and Documenting

Data

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Chapter 5

• Validating Data
– Purpose: ensure accuracy of
data and reduce errors
– Crucial assessment step

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Chapter 5
• Data requiring validation
– Discrepancies/gaps between
•Subjective and objective data
•Client responses to same question
– Findings that are very abnormal
and/or inconsistent with other
findings
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Chapter 5
• Methods of Validation
– Repeat assessment to recheck data
– Ask additional questions
– Verify data with another health care
provider
– Compare subjective and objective
data
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Chapter 5

• Identification of Areas Where Data Are

Missing
– Comes from
•Grouping data
•Establishing initial data base

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Chapter 5
• Documenting Data
– Required by:
•Nurse Practice Act
•Accreditation or reimbursement
agencies
•Institutional agency policy and
procedure
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Chapter 5

• Purpose of Documentation
– Provide health care team with data
base that serves as foundation for
client care
– If findings are not documented, the
assessment phase of the nursing
process is interpreted as not done!
Copyright © 2007 Lippincott Williams & Wilkins.
Chapter 5

• Information requiring documentation

– Subjective and biographic data
– Present health concern (COLDSPA)
– Past health and family histories
– Lifestyle and health practices
– Objective data (findings from PE)
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Chapter 5

• Guidelines for documentation

– Document legibly or print neatly in
non-erasable ink.
– Use correct grammar and spelling.
Use ONLY abbreviations that are
acceptable to and approved by
the institution serving the client.
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Chapter 5

• Guidelines for documentation, cont.

– Avoid wordiness that creates
redundancy.
– Use phrases instead of sentences.
– Record data findings, not how they
were obtained.

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Chapter 5
• Guidelines for documentation, cont.
– Write entries objectively without
making premature judgments or
diagnoses.
– Record the client’s understanding
and perception of problems.
– Avoid recording the word “normal”
for normal findings.
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Chapter 5
• Guidelines for documentation, cont.
– 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 PE.
Copyright © 2007 Lippincott Williams & Wilkins.
Chapter 5

• Assessment forms used for

documentation
– Open-ended
– Cued/checklist
– Integrated cued checklist
– Nursing Minimum Data Set (NMDS)
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Chapter 5

• Other forms used for documentation

– Frequent or Ongoing Assessment
Form
– Progress Notes
– Focused or Specialty Area
Assessment Form

Copyright © 2007 Lippincott Williams & Wilkins.