Documentation of Data Flashcards
The last step of health assessment is the _____
documentation of data
This involves the recording of the client assessment findings.
Documentation of Data
Purposes of Assessment Documentation
Provides a chronologic source of client assessment data and a progressive record of assessment findings that outline the client’s course of care.
Ensures that information about the client and family is easily accessible to members of the health care team; provides a vehicle for communication; and prevents fragmentation, repetition, and delays in carrying out the plan of care.
Establishes a basis for screening or validating proposed diagnoses.
Acts as a source of information to help diagnose new problems.
Offers a basis for determining the educational needs of the client, family and significant others.
Purposes of Assessment Documentation
Provides a basis for determining eligibility for care and reimbursement.
Constitutes a permanent legal record of the care that was or was not given to the
client.
Forms a component of client acuity system or client classification systems. Numeric values may be assigned to various levels of care to help determine the staffing mix for the unit.
Provides access to significant epidemiologic data for future investigations and research and educational endeavors.
Promotes compliance with legal, accreditation, reimbursement, and professional standard requirements.
Information Requiring Documentation
Subjective data
Objective data
Subjective data
- Biographic data
- Present health condition review
- Past health history data
- Family health history data
- Lifestyle and health practices information
Includes inspection, palpation, percussion, and auscultation
Objective Data
Help to further define the client’s problems, establish baseline data for ongoing assessments, and validate the subjective data obtained during the nursing history interview.
objective data
Guidelines for Documentation
Keep confidential all documented information in the client record.
Document legibly or print neatly in non-erasable ink.
Use correct grammar and spelling.
Avoid wordiness that creates redundancy.
Use phrases instead of sentences to record data.
Record data findings, not how they were obtained.
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.
Recordcompleteinformationand details of all client symptoms o rexperiences.
Guideliness for Documentation
Record data findings, not how they were obtained.
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.
Record complete information and details of all client symptoms or experiences.
Include additional assessment content when applicable.
Support objective data with specific observations obtained during the physical examination.
General Rule in Documenting Objective Data
- Make notes while performing the assessments, and document as concisely as possible.
- Avoid documenting with general non-descriptive or non-measurable terms such as normal, abnormal, good, fair, satisfactory, or poor.
- Instead, use descriptive and measurable terms (e.g. 3 inches in diameter, red excoriated edges, with purulent yellow drainage) about what you inspected, palpated, percussed, and auscultated.
_______ have been developed to ensure that content in documentation and assessment data meets regulatory requirements and provides a thorough database.
Standardized assessment forms
The type of assessment form used for documentation
Initial assessment form
Frequent or ongoing assessment form
Focused or specialty area assessment form.
This is called as a nursing admission or admission database.
INITIAL ASSESSMENT FORM
Types of Initial Assessment Documentation Forms
- Open-ended Form (Traditional Forms)
- Cued or checklist Forms
- Integrated Cued Checklist
- Nursing Minimum Data Set
This form helps the staff to record and retrieve data for frequent reassessments. It streamline the documentation process and prevent needless repetition of data.
Frequent or Ongoing Assessment Form
Examples of this form includes frequent vital sign sheet, assessment flow chart, and progress notes.
Frequent or Ongoing Assessment Form
It focused on one major area of the body for clients who have a particular problem. Examples include the cardiovascular or neurologic assessment documentation forms. This form may also be customized.
Focused or Specialty Area Assessment Form
is usually the abbreviated versions of admission data sheets, with specific assessment data related to the purpose of the assessment.
focused or specialty area assessment form
