Validating and Documenting Data

Question 1

− Act of “double-checking” or verifying
data to confirm that it is accurate
and factual or
− comparison of data with another
source to determine data accuracy.

Answer 1

Validation

Question 2

Validating the

A
C
D

Answer 2

Accuracy, Clarity, and Details of data

Question 3

is the process of confirming or verifying that the
subjective and objective data you have collected are reliable and
accurate.

Answer 3

Validation of data

Question 4

are subjective or objective data that can be directly
observed by the nurse; that is what the client says or what the nurse
can see, hear, feel, smell, or measure.

Answer 4

CUES

Question 5

are the nurse’s interpretation or conclusion made
based on the cues.

Answer 5

INFERENCES

Question 6

When to Validate?

Answer 6

When there are discrepancies.
- When there is a lack of objectivity in the data.

Question 7

Steps of validation

Answer 7

1. Decide
2. Determine
3. Identify

Question 8

between the subjective and objective data.
between what the client says at one time versus another time.

● Findings that are highly abnormal and/or inconsistent with other findings.

Answer 8

Discrepancies or gaps

Question 9

Determining ways to validate the

Answer 9

Validating Data

Question 10

your own data through a repeat
assessment.

Answer 10

Recheck

Question 11

data with the client by asking
additional questions.

Answer 11

Clarify

Question 12

the data with another health care
professionals.

Answer 12

Verify

Question 13

your objective findings with your
subjective findings to uncover discrepancies.

Answer 13

Compare

Question 14

Not all data required __________

Answer 14

VALIDATION

Question 15

determining nursing diagnoses,
collaborative problems, referrals.

Answer 15

• Analysis of data

Question 16

information that the client or significant others tell the
nurse.

Answer 16

Subjective data

Question 17

what the nurse observes through inspection, palpation,
percussion, or auscultation.

Answer 17

Objective data

Question 18

No matter which approach is used,
general rules apply:
● Make notes as you perform 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 specific descriptive and
measurable terms

Answer 18

Documenting Data

Question 19

nurses are required to verbally share their
subjective and objective assessment findings in an
effective manner to other health care workers.

• Sharing of ideas with colleagues and other health
  professionals about some aspect of the client’s care.

 - other terms use: endorsement, handover, reporting

Answer 19

Handoff

Question 20

To prevent data communication errors, it is important to:
Use a standardized method of data communication such as

I S B A R

Answer 20

INTRODUCTION
SITUATION
BACKGROUND
ASSESSMENT
RECOMMENDATION

Question 21

To prevent data communication errors, it is
important to:
◦ Communicate face to face with good eye contact
◦ Allow time for the receiver to ask questions
◦ Provide documentation of data you are sharing
◦ Validate what the receiver has heard by
questioning or asking him or her to summarize
your report
◦ When reporting over a telephone, ask the receiver
to read back what he or she heard you report and
document the phone call with time, receiver,
sender and information shared.

Answer 21

Verbal Communication of Data