Chapter 4 - Validating and documenting data

Question 1

Purpose of Validation

Answer 1

confirming or verifying that the subjective and objective data you have collected are reliable and accurate

Question 2

Data Requiring Validation

Answer 2

Discrepancies or gaps between the subjective and objective data.

Discrepancies or gaps between what the client says at one time versus another time.

findings that are highly abnormal and/or inconsistent with other findings

Question 3

Methods of Validation

Answer 3

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 your objective findings with your subjective findings to uncover discrepancies

Question 4

Purpose of Documentation

Answer 4

documentation of assessment data is to promote effective communication among multidisciplinary health team members to facilitate safe and efficient client care.

Question 5

True or False

documentation is a legal record of the clients care.

Answer 5

True

Question 6

Information Requiring Documentation

Answer 6

subjective data, objective data.

Question 7

Guidelines for Documentation

Answer 7

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.

Record data findings,

Write entries objectively without making premature judgments or diagnoses

Avoid recording the word “normal” for normal findings

Question 8

Vague documentation or Clear and concise

Recent and remote memory intact

Answer 8

clear and concise

Question 9

Vague documentation or Clear and concise

Vital signs good

Answer 9

Vague

should say “temperature: 98.6 degrees F; Pulse 66 regular Respirations 18, Blood pressure: 160/88”

Question 10

Vague documentation or Clear and concise

Reports no change in appetite (list 24-hour diet recall on a typical day)

Answer 10

Clear and concise

Question 11

Vague documentation or Clear and concise

Heart rate regular

Answer 11

Vague

shouls say “Heart regular rate and rhythm: S1 and S2 present; S1 loudest at the apex, S2 loudest at base; no S3,S4, murmur, rub, or gallop”

Question 12

Vague documentation or Clear and concise

Hears poorly

Answer 12

vague

should say ““My wife says I always turn the radio and TV up too loud so I guess I am hard of hearing”

Question 13

Types of assessment forms

Answer 13

open-ended, cued or checklist, integrated cued checklist, and nursing minimum data set (NMDS) forms

Question 14

Initial Assessment Form

Answer 14

is called a nursing admission or admission database

Question 15

Frequent or Ongoing Assessment Form

Answer 15

flowcharts - allows for rapid comparison of recorded assessment data from one time period to the next

Question 16

OPEN-ENDED FORMS (TRADITIONAL FORM)

Answer 16

• Calls for narrative description of problem and listing of topics.
• Provides lines for comments.
• Individualizes information.
• Provides “total picture,” including specific complaints and symptoms in the client’s own words.
• Increases risk of failing to ask a pertinent question because questions are not standardized.
• Requires a lot of time to complete the database.

Question 17

CUED OR CHECKLIST FORMS

Answer 17

• Makes documentation somewhat like data entry because it requires nurse to place check marks in boxes instead of writing narrative.
• Poses chance that a significant piece of data may be missed because the checklist does not include the area of concern.

Question 18

INTEGRATED CUED CHECKLIST

Answer 18

-Helps cluster data, focuses on nursing diagnoses, assists in validating nursing diagnosis labels, and combines assessment with problem listing in one form.

Question 19

NURSING MINIMUM DATA SET

Answer 19

• Comprises format commonly used in long-term care facilities.
• Includes specialized information, such as cognitive patterns, communication (hearing and vision) patterns, physical function and structural patterns, activity patterns, restorative care, and the like.

Question 20

Focused or Specialty Area Assessment Form

Answer 20

focused on one major area of the body for clients who have a particular problem

Question 21

SBAR

Answer 21

passing along information to the next nurse

situtation
backgroud
assessment
recommendation

Question 22

What is a “Handoff”

Answer 22

this occurs anytime one health care provider is transferring client care responsibilities for the client’s care to another health care provider