Chapter 4

Validating and Documenting

Data
Validation of Data

 Verify that subjective and objective data are

reliable and accurate.

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Steps of Validation
 Deciding whether data require validation
 Determining ways to validate the data
 Identifying areas where data are missing

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Data Requiring Validation

 Discrepancies or gaps between subjective and objective

data
 Discrepancies in what the client says at one time versus
another time
 Abnormal and/or inconsistent findings

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Methods of Validation
 Repeat assessment.
 Clarify data with client.
 Verify with another health care professional.
 Compare objective findings with subjective findings.

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Purposes for Documentation #1
 Provides a chronologic source of client assessment data
and a progressive record of assessment findings that
outline the client’s course of care.
 Ensures that information about the client and family is
easily accessible to members of the health care team;
provides a vehicle for communication; and prevents
fragmentation, repetition, and delays in carrying out the
plan of care.

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Purposes for Documentation #2

 Establishes a basis for screening or validating proposed

diagnoses.
 Acts as a source of information to help diagnose new
problems.
 Offers a basis for determining the educational needs of
the client, family, and significant others.

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Purposes for Documentation #3
 Provides a basis for determining eligibility for care and
reimbursement. Careful recording of data can support
financial reimbursement or gain additional
reimbursement for transitional or skilled care needed by
the client.
 Constitutes a permanent legal record of the care that
was or was not given to the client.

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Purposes for Documentation #4
 Forms a component of client acuity system or client
classification systems. Numeric values may be assigned
to various levels of care to help determine the staffing
mix for the unit.
 Provides access to significant epidemiologic data for
future investigations and research and educational
endeavors.
 Promotes compliance with legal, accreditation,
reimbursement, and professional standard requirements.

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Documenting Data #1
 Keep confidential all documented information in the
client record.
 Document legibly or print neatly in nonerasable ink.
 Use correct grammar and spelling.
 Avoid wordiness that creates redundancy.
 Use phrases instead of sentences to record data.

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Documenting Data #2
 Record data findings, not how they were obtained.
 Write entries objectively without making premature
judgment.
 Record the client’s understanding and perception of
problems.
 Avoid recording the word “normal” for normal findings.

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Documenting Data #3
 Record complete information and details for all client
symptoms.
 Include additional assessment content when applicable.
 Support objective data with specific observations
obtained during the physical examination.

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Question #1
Which guideline should the nurse follow for documentation?
A. Write “normal” for normal findings
B. Use phrases instead of sentences
C. Exclude client’s understanding
D. Describe how data were obtained

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Answer to Question #1
B. Use phrases instead of sentences.
When documenting, the nurse should remember to use
phrases instead of sentences, avoid using the word
“normal” for normal findings, include the client’s
understanding, and record data findings, not how they
were obtained.

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Assessment Forms for Documentation

 Initial assessment form: nursing admission or admission

database
 Frequent or ongoing assessment form: flow charts that
help staff to record and retrieve data for frequent
reassessments
 Focused or specialty area assessment form: focused on
one major area of the body for clients who have a
particular problem

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Question #2

Which is a feature of an open-ended documentation form?

A. Consists of check boxes
B. Promotes use by different caregivers
C. Promotes rapid documentation
D. Provides narrative description

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Answer to Question #2
D. Provides narrative description.
An open-ended documentation form provides a narrative
description of problems. A checklist form uses check boxes
and promotes rapid documentation. An integrated cued
checklist and a nursing minimum data set promote use by
different caregivers.

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Question #3

Is the following statement true or false?

In a cued or checklist form, there is a possibility of missing
a significant piece of information.

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Answer to Question #3

True.
In a cued or checklist form, there is a possibility of missing
a significant piece of information because the checklist does
not include the area of concern.

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Verbal Communication of Findings (Using
SBAR)

 Use a standardized method of data communication such as

SBAR (Situation, Background, Assessment, Recommendation).
 Communicate face to face with good eye contact.
 Allow time for the receiver to ask questions.
 Provide documentation of the data you are sharing.
 Validate what the receiver has heard by questioning or asking
the receiver to summarize your report.
 When reporting over a telephone, ask the receiver to read
back what the receiver heard you report and document the
phone call with time, receiver, sender, and information shared.

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