Handout 4 Flashcards
is the process of confirming or verifying that the subjective and objective data you have collected are reliable and accurate
◈ Validation of data
◈ The steps of validation include:
🞚 deciding whether the data require validation,
🞚 determining ways to validate the data,
🞚 and identifying areas for which data are missing.
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 FlNDINGS WITH YOUR SUBJECTIVE FlNDings
🞚 example, take the client’s temperature again with a different thermometer.
◈ RECHECK YOUR OWN DATA THROUGH A REPEAT ASSESSMENT .
🞚 For example, if a client is holding his abdomen the nurse may assume he is having abdominal pain, when actually the client is very upset about his diagnosis and is feeling nauseated.
◈ CLARIFY DATA WITH THE CLIENT BY ASKING ADDITIONAL QUESTIONS
🞚 example, ask a more experienced nurse to listen to the abnormal heart sounds you think you have just heard.
◈ VERIFY THE DATA WITH ANOTHER HEALTH CARE PROFESSIONAL
to uncover discrepancies. For example, if the client states that she “never gets any time in the sun,” yet has dark, wrinkled, suntanned skin, you need to validate the client’s perception of never getting any time in the sun by asking exactly how much time is spent working, sitting, or doing other activities outdoors. Also, ask what the client wears when engaging in outdoor activities
◈ COMPARE YOUR OBJECTIVE FlNDINGS WITH YOUR SUBJECTIVE FlNDings
◈ Promote effective communication among multidisciplinary health team members to facilitate safe and efficient client care.
PURPOSE OF DOCUMENTATION
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, not how they were obtained
◈ Write entries objectively without making premature judgments or diagnoses
Use quotation marks to identify clearly the client’s responses.
◈ Record the client’s understanding and perception of problems
◈ Avoid recording the word “normal” for normal findings
◈ Record complete information and details for all client symptoms or experiences
◈ Include additional assessment content when applicable.
◈ Support objective data with specific observations obtained during the physical examination
is called a nursing admission or admission database
Initial Assessment Form
◈ Four types of frequently used initial assessment documentation forms are known as
🞚 open-ended,
🞚 cued or checklist,
🞚 integrated cued checklist, and
🞚 nursing minimum data set
TYPES OF ASSESSMENT FORMS
Initial Assessment Form
Frequent or Ongoing Assessment Form
Focused or Specialty Area Assessment Form
FUNCTIONAL ASSESSMENT TOOLS
The nursing process includes all ot the following except
a rigid set of steps for nurses to follow
- Which of the following is the correct order of the nursing process?
Assessing, Diagnosing, Planning, Implementing, Evaluating
