Chapter 4 - Validating and documenting data Flashcards
Purpose of Validation
confirming or verifying that the subjective and objective data you have collected are reliable and accurate
Data Requiring Validation
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
Methods of Validation
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
Purpose of Documentation
documentation of assessment data is to promote effective communication among multidisciplinary health team members to facilitate safe and efficient client care.
True or False
documentation is a legal record of the clients care.
True
Information Requiring Documentation
subjective data, objective data.
Guidelines for Documentation
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
Vague documentation or Clear and concise
Recent and remote memory intact
clear and concise
Vague documentation or Clear and concise
Vital signs good
Vague
should say “temperature: 98.6 degrees F; Pulse 66 regular Respirations 18, Blood pressure: 160/88”
Vague documentation or Clear and concise
Reports no change in appetite (list 24-hour diet recall on a typical day)
Clear and concise
Vague documentation or Clear and concise
Heart rate regular
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”
Vague documentation or Clear and concise
Hears poorly
vague
should say ““My wife says I always turn the radio and TV up too loud so I guess I am hard of hearing”
Types of assessment forms
open-ended, cued or checklist, integrated cued checklist, and nursing minimum data set (NMDS) forms
Initial Assessment Form
is called a nursing admission or admission database
Frequent or Ongoing Assessment Form
flowcharts - allows for rapid comparison of recorded assessment data from one time period to the next
OPEN-ENDED FORMS (TRADITIONAL FORM)
- 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.
CUED OR CHECKLIST FORMS
- 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.
INTEGRATED CUED CHECKLIST
-Helps cluster data, focuses on nursing diagnoses, assists in validating nursing diagnosis labels, and combines assessment with problem listing in one form.
NURSING MINIMUM DATA SET
- 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.
Focused or Specialty Area Assessment Form
focused on one major area of the body for clients who have a particular problem
SBAR
passing along information to the next nurse
situtation
backgroud
assessment
recommendation
What is a “Handoff”
this occurs anytime one health care provider is transferring client care responsibilities for the client’s care to another health care provider
