DEVELOPMENTAL ASSESSMENT Flashcards
process of confirming or verifying that the subjective and objective data collected are reliable and accurate
validation of data
conditions that require data to be rechecked and validated
discrepancies or gaps between subjective and objective data
discrepancies or gaps between what the client says at one time versus another time
findings that are highly abnormal
ways to validate data
recheck through repeat assessment
clarify data by asking questions
verify data with another healthcare prof
compare objective and subjective
primary reason for documentation of assessment data
promote effective communicaiton among multidisciplinary health team members
documented assessment data provide the healthcare teams with a __ that becomes the foundation for care of the client
database
typically consists of biographical data, present health concern and symptoms,, personal health history, family history, and lifestyle and health practices
subjective data
typically consists of the client’s name, age, occupation, ethnicity, and support systems
biographical data
is recorded in statements that reflect the client’s current symptoms
present health concern
tells the nurse about the events that happened before the client’s admission to the healthcare center
personal health history
includes family information about the client’s biologic family
family health history
includes details about risk behaviors such as poor nutrition, excess sun exposure, past or present smoking
lifestyle and health practices information
standardized assessment forms have been developed to ensure that content in documentation and assessment data meets regulatory requirements and provides a thorough database
initial assessment form
the initial assessment form is called a
nursing admission or admission database
created flowcharts that help staff to record and retrieve data for frequent reassessments
frequent or ongoing assessment form
some institutions may use assessment form that are focused on one major area of the body for clients who have a particular problem
focused or specialty area assessment form
