Weber

Health Assessment in Nursing

Chapter 05:
Validating and
Documenting Data
Copyright © 2008 Wolters Kluwer Health | Lippincott Williams & Wilkins
Validating Data
• Purpose of validation
– To verify that subjective and
objective data are reliable and
accurate

Copyright © 2008 Wolters Kluwer Health | Lippincott Williams & Wilkins

Validating Data
• Purpose of validation
– Steps of validation:
•Decide if data require validation
•Determine ways to validate data
•Identify areas of missing data

Copyright © 2008 Wolters Kluwer Health | Lippincott Williams & Wilkins

Validating Data (Cont’d)
• Data requiring validation
– Discrepancies between subjective and
objective data
– Discrepancies in what the client says
at one time, then at another time
– Abnormal and/or inconsistent findings

Copyright © 2008 Wolters Kluwer Health | Lippincott Williams & Wilkins

Validating Data (Cont’d)
• Methods of validation
– Repeat assessment
– Clarify data with client
– Verify with another healthcare
professional
– Compare findings
Copyright © 2008 Wolters Kluwer Health | Lippincott Williams & Wilkins
Validating Data (Cont’d)
• Identification of areas where data are
missing
– Comes from
•Grouping data
•Establishing initial data base

Copyright © 2008 Wolters Kluwer Health | Lippincott Williams & Wilkins

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

Copyright © 2008 Wolters Kluwer Health | Lippincott Williams & Wilkins

Documenting Data (Cont’d)
• Purpose of documentation
– Provide chronologic source of data
– Prevent fragmentation, repetition
– Establish basis for screening
– To help diagnose new problems

Copyright © 2008 Wolters Kluwer Health | Lippincott Williams & Wilkins

Documenting Data (Cont’d)
• Purpose of documentation (cont’d)
– Determine educational needs of
client, family, and significant others
– Eligibility for reimbursement
– Legal record of care

Copyright © 2008 Wolters Kluwer Health | Lippincott Williams & Wilkins

Documenting Data (Cont’d)
• 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)

Copyright © 2008 Wolters Kluwer Health | Lippincott Williams & Wilkins

Documenting Data
• 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

Copyright © 2008 Wolters Kluwer Health | Lippincott Williams & Wilkins

Documenting Data (Cont’d)
• Guidelines for documentation (cont’d)
– Avoid wordiness that creates
redundancy
– Use phrases instead of sentences
– Record data findings, not how they
were obtained

Copyright © 2008 Wolters Kluwer Health | Lippincott Williams & Wilkins

Documenting Data (Cont’d)
• Guidelines for documentation (cont’d)
– 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
Copyright © 2008 Wolters Kluwer Health | Lippincott Williams & Wilkins
Documenting Data (Cont’d)
• Guidelines for documentation (cont’d)
– 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 © 2008 Wolters Kluwer Health | Lippincott Williams & Wilkins
Question

Which of the following guidelines 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.
Copyright © 2008 Wolters Kluwer Health | Lippincott Williams & Wilkins
Answer

b. Use phrases instead of sentences.

Rationale: 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.

Copyright © 2008 Wolters Kluwer Health | Lippincott Williams & Wilkins

Documenting Data (Cont’d)

• Assessment forms for documentation

– Initial Assessment Form
– Frequent or Ongoing Assessment
Form
– Focused or Specialty Area
Assessment Form

Copyright © 2008 Wolters Kluwer Health | Lippincott Williams & Wilkins

Documenting Data (Cont’d)

• Initial Assessment Form

– Open-ended
– Cued or checklist
– Integrated cued checklist
– Nursing minimum data set

Copyright © 2008 Wolters Kluwer Health | Lippincott Williams & Wilkins

Question
Which of the following 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

Copyright © 2008 Wolters Kluwer Health | Lippincott Williams & Wilkins

Answer
d. Provides narrative description.
Rationale: 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.

Copyright © 2008 Wolters Kluwer Health | Lippincott Williams & Wilkins

Question

Tell whether the following statement is

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

Copyright © 2008 Wolters Kluwer Health | Lippincott Williams & Wilkins

Answer

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.

Copyright © 2008 Wolters Kluwer Health | Lippincott Williams & Wilkins

Documenting Data (Cont’d)

• Frequent or Ongoing Assessment Form

– Frequent vital signs sheet
– Assessment flow chart
– Progress notes

Copyright © 2008 Wolters Kluwer Health | Lippincott Williams & Wilkins

 End of Presentation

Copyright © 2008 Wolters Kluwer Health | Lippincott Williams & Wilkins