chap 4 Flashcards
validation of data
process of confirming/verifying subjective/objective data you have collected are reliable/accurate
main purpose of validating data
making sure data is reliable/accurate
failure to validate may result in…
premature closure of the assessment/collection of inaccurate data
steps of validation
- decide whether data requires validation
- determine ways to validate data
- identify areas where data is missing
identification of areas which data is missing
once initial database is established, you can identify areas for which more data is needed
data requiring validation
- gaps between subjective/objective data
- discrepancies in what client says
- abnormal and/or inconsistent findings
methods of validation
- repeat assessment
- clarify data with client
- verify w/ another health care professional
- compare objective findings w/ subjective findings
documentation of data
- immediately give verbal reporting of data
- enter initial database into computer the same day patient is admitted
- summarize objective/subjective data in concise, comprehensive, and easily retrievable manner
- use good grammar
- use patient’s own words
- avoid nonspecific terms
purpose of documentation
- provides chronologic source of client assessment
- ensures info about client and family is easily accessible
- establish basis for screening
- info to help diagnose new problems
- determine educational needs
- provides basis for determining eligibility for care/reimbursement
when documenting
- keep confidential
- document legibility
- use correct grammar/spelling
- avoid wordiness
- use phrases instead of sentences
- record data findings
- write entries objectively
- record the client’s understanding and perception of problem
- avoid recording the word “normal” for normal findings
- record complete info
- include additional content
- support objective data w/ specific observations
electronic health record (EHR)
more comprehensive health status of the client and not only medical status
electronic medical record (EMR)
patient medical record from a SINGLE medical practice, hospital, pharmacy
primary reason for documentation of assessment data
promote effective communication among multidisciplinary health team members
assessment forms for documentation
- initial assessment
- frequent/ongoing
- focused/specialty
initial assessment form
- nursing admission or admission database
- 4 types frequently used
initial assessment form: open ended forms
- calls for narrative description of problem and listing of topics
- provides lines for comments
- provides “total picture”
- increases risk for failing to ask pertinent question
- requires a lot of time to complete the database
initial assessment form: cued or checklist forms
- standardized data collection
- lists info that alerts nurse to specific problems/symptoms
- includes a comment section after each category
- prevents missed questions
- promotes easy, rapid documentation
- poses chance that a piece of data may be missed
initial assessment form: integrated cued checklist
- combines assessment data w/ identified nursing diagnosis
- helps cluster data, focuses on nursing diagnosis, assists in validating nursing diagnosis labels, combines assessment
- promotes use by different levels of caregivers
initial assessment form: nursing minimum data set
- comprises format commonly used in long-term care
- cued forma that prompts nurse for specific criteria
- includes specialized info
- meets needs of multiple data users in health care system
- establishes comparability of nursing data
frequent/ongoing assessment form
- various institutions have created flowcharts
- flow sheets streamline documentation process
focused specialty assessment form
- cardiovascular or neurologic assessment documentation forms
- forms may be customized
- usually abbreviated versions of admission data sheets
3 crucial aspect of health assessment
- validation
- documentation
- verbal communication
SBAR
- situation
- background
- assessment
- recommendation
situation
state why you need to communicate client data
background
describe the events that led up to current situation
assessment
state subjective and objective data you have collected
recommendation
suggest what you believe needs to be done for client based on your assessment findings
