ORGANIZING DATA & VALIDATING Flashcards
Also referred to as nursing health history, nursing assessment or database form
ORGANIZING DATA
what type of asset format is;
- Gordon’s Functional Health Patterns
- Orem’s Self-Care Model
- Roy’s Adaptation Model
CONCEPTUAL MODELS OR FRAMEWORKS
what type of assessment format that Includes factors and attitudes that influence levels of wellness
WELLNESS MODELS
what type of assessment format is;
- Body Systems Model
- Maslow’s Hierarchy of Needs
- Developmental Theories
NON - NURSING MODELS
The act of “double-checking” or
verifying data to confirm that it is complete, factual and accurate.
VALIDATING DATA
subjective or objective data that can be directly observed by the nurse
CUES
nurse’s interpretation or conclusions made based on the cues
INFERENCE
Recording of client data
DOCUMENTING DATA
oral, written or computer-based communication intended to convey information
to others.
REPORT
also called chart or client record; a formal legal document that provides evidence of client’s care; can be written or computer
based.
RECORD
The process of making an entry on a client record
RECORDING, CHARTING OR DOCUMENTING
is accountable and should document according to organization policies and universal standards.
NURSES
Time may be recorded in the
conventional manner (12 hour; AM / PM) or according to 24-hour (military) clock
DATE AND TIME
Documenting should be done as soon as possible after an assessment or intervention. (Do not document before
assessment or intervention is done)
TIMING
Must be legible or easy to read. Hand printing or easily understood handwriting is permissible. (avoid script
or shorthand)
LEGIBILITY
Written in “dark ink or permanent pen.”
- For Electronic Records, changes are made in accordance with software
guidelines.
PERMANENCE
Use only commonly accepted
abbreviations, symbols, and terms. Refer to approved list given by the institution.
ACCEPTED TERMINOLOGY
Incorrect spelling gives a negative impression to the reader and decreases the credibility of the nurse.
CORRECT SPELLING
Includes name and title of the nurse.
- For electronic records each nurse has his
or her own code
SIGNATURE
Client’s name and identifying
information should be stamped or written on each page of the clinical record. Do not identify charts by room number. Special care is needed when
caring for clients with the same last name
ACCURACY
Document events in the order in which they occur.
SEQUENCE
Record only information that pertains to client’s health problems and care. Recording irrelevant information may be
considered invasion of client’s privacy and/or libelous.
APPROPRIATENESS
Not all data that a nurse obtains about a client can be recorded. However, the
information that is recorded needs to be complete and helpful to the client and
the health care team.
COMPLETENESS
Recordings need to be brief as well as complete.
- Client’s name and the word “client” are omitted.
- End each thought with a period.
CONCISENESS
Accurate and complete documentation should give legal protection to the nurse,
the health care team, and the institution
LEGAL PRUDENCE
