Validating and Documenting Data Flashcards
− 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.
Validation
Validating the
A
C
D
Accuracy, Clarity, and Details of data
is the process of confirming or verifying that the
subjective and objective data you have collected are reliable and
accurate.
Validation of data
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.
CUES
are the nurse’s interpretation or conclusion made
based on the cues.
INFERENCES
When to Validate?
When there are discrepancies.
- When there is a lack of objectivity in the data.
Steps of validation
- Decide
- Determine
- Identify
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.
Discrepancies or gaps
Determining ways to validate the
Validating Data
your own data through a repeat
assessment.
Recheck
data with the client by asking
additional questions.
Clarify
the data with another health care
professionals.
Verify
your objective findings with your
subjective findings to uncover discrepancies.
Compare
Not all data required __________
VALIDATION
determining nursing diagnoses,
collaborative problems, referrals.
- Analysis of data
information that the client or significant others tell the
nurse.
Subjective data
what the nurse observes through inspection, palpation,
percussion, or auscultation.
Objective data
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
Documenting Data
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
Handoff
To prevent data communication errors, it is important to:
Use a standardized method of data communication such as
I S B A R
INTRODUCTION
SITUATION
BACKGROUND
ASSESSMENT
RECOMMENDATION
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.
Verbal Communication of Data
