Validation of Data & Documentation of Data Flashcards
It is the process of confirming or verifying
that the subjective and objective data the
nurse have collected are reliable and
accurate
VALIDATING DATA
the common term used in the field of
nursing when it comes to
documentation
CHARTING
traditional form of charting
source-oriented record
Narrative Charting
give focus on the problems that patients
face
Problem-Oriented Record
usually used since it gives a quick look at
the observation of each nurse as well as
the nursing action on each observation
SOAP Formats
includes the patient’s
complaints or perception of the present
problem sited
Subjective data
includes the nurse’s
observation using his or her clinical eye
Objective data
the inference
made by the nurse from the two types of
data. This is the part wherein the problem
is stated. The nursing problem is stated in
a form of nursing diagnoses using the
NANDA
Assessment
the nursing actions
to be made in order to solve the stated
problem. This part can be revised.
Plan
This is the part wherein specific nursing
actions are stated
Intervention
This is the part wherein the nurse
evaluates the reaction of the
patient or progress of the
problem being solved.
Evaluation
This is the section that states the changes
made in order to further resolve the problem.
Revision
This type of charting involves Data,
Action and Response category.
This is a client-focused charting
Focus Charting (FDAR)
a model of communication
one of the most common handover
mnemonic models used in health care
The SBAR
Used to manage the huge volume of
information required in contemporary
health care
Electronic Health Records (EHRs)
