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Chapter 4 Validating and Documenting Data
Individual Health Assessment (Prairie View A&M University)
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Chapter 4 Validating and Documenting Data
Learning Objectives
1. Describe the significance and process for validation of client data.
a. Validation: verification that subjective & objective data are reliable &
accurate.
b. Failure to validate:
i. Result in premature closure of assessment
ii. Collection of innacurate data
iii. Nurse’s judgement is made on unreliable data, which causes
diagnostic errors.
c. process:
i. Deciding whether the data requires validation
ii. Determining ways to validate the data
iii. Identify areas where data is missing.
2. Discuss situations that require client data to be rechecked or verified.
a. Discrepancies/ gaps btw subj. & obj. data
i. Ex: a pt tells you they are happy despite learning that he has
terminal cancer
b. Discrepancies/ gaps btw what the client says one time v. the other.
i. Ex: pt says they’ve never had surgery but later says they
removed her appendix
c. Findings are abnormal/ inconsistent w/ other findings
i. Ex: pt has a temp of 104 F & is resting comfortably, & sking is
warm to touched & not flushed.
d. NOT ALL data needs to be validated
i. Ex: verifying vital signs if within normal range.
e. Methods of validation:
i. Repeat assessment
ii. Clarify w/ the client by asking additional questions
iii. Verify the data w/ another HCT member
iv. Compare obj. findings w/ subj. findings
3. Describe the multiple purposes of accurate and timely documentation of client
data.
a. Documentation provides a chronological source of client assessment
data & a progressive record of assessment findings that outline the
client’s course of care.
b. Purposes:
i. Promote effective communication among the HCT to facilitate
safe & efficient care.
ii. It becomes the foundation for care of the client.
iii. Ensures that info about the pt is easily accessible.
iv. Provides a basis for determining eligibility for care &
reimbursement.
v. Permanent legal record
vi. Resource for communication
vii. Prevents fragmentation, repetition, & delays when caring for a
pt.
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4. Identify safe guidelines for documentation of client data.
a. Keep confidential all documented info (HIPAA)
b. Document legibly/ print neatly w/ nonerasable ink.
i. Correct errors by drawing one line through the entry, writing
“Error”, & initialing the entry
c. Use correct grammar & spelling
d. Avoid wordiness that creates redundancy
e. Uses phrases rather than complete sentence
f. Record data findings, not how they were obtained
g. Write entries objectively w/o making premature judgments.
h. Record client’s understanding & perception of problems
i. Avoid recording the word “normal” for normal findings
j. Record comple infor & details for all client symptoms.
k. Include additional assessment content when applicable.
l. Support obj. dat w/ specific observations obtained during physical
exam.
TABLE 4-1 Examples of Vague Versus Clear and Concise
Documentation of Data
Vague Documentation Clear and Concise Documentation
Source and reliability of
information: Client
Client awake, alert, and oriented to person, place, time, and events. Initiates
and maintains conversation. Asks and answers questions that are
appropriate.
Memory intact
Recent and remote memory intact.
Vital signs good
Temperature: 98.6 degrees F; Pulse 66 regular Respirations 18, Blood pressure:
160/88
Skin color normal
Skin pink with consistent pigmentation
Appetite good
Reports no change in appetite (list 24-hour diet recall on a typical day)
Swelling of ankles
Pitting edema 3+ of both ankles that lasts 10 seconds
Hears poorly
“My wife says I always turn the radio and TV up too loud so I guess I am hard of
hearing”
Heart rate regular
Heart regular rate and rhythm: S1 and S2 present; S1 loudest at the apex, S2
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loudest at base; no S3,S4, murmur, rub, or gallop
Chest sounds clear
Anterior, posterior, and bilateral chest sounds clear to auscultation
Normal bowel sounds
5–20 bowel sounds per minute, active bowel sounds in all 4 quadrants.
Voids a lot
Polyuria, urinary output (UOP) = 3,000 mL/day
5. Types of assessment forms
BOX 4-2
FEATURES OF TYPES OF INITIAL ASSESSMENT
DOCUMENTATION FORMS
OPEN-ENDED FORMS (TRADITIONAL FORM)

Calls for narrative description of problem and listing of topics.

Provides lines for comments.

Individualizes information.

Provides “total picture,” including specific complaints and symptoms in the
client’s own words.

Increases risk of failing to ask a pertinent question because questions are
not standardized.

Requires a lot of time to complete the database.
CUED OR CHECKLIST FORMS

Standardizes data collection.

Lists (categorizes) information that alerts the nurse to specific problems or
symptoms assessed for each client (see Fig. 4-1).

Usually includes a comment section after each category to allow for
individualization.

Prevents missed questions.

Promotes easy, rapid documentation.

Makes documentation somewhat like data entry because it requires nurse
to place check marks in boxes instead of writing narrative.

Poses chance that a significant piece of data may be missed because the
checklist does not include the area of concern.
INTEGRATED CUED CHECKLIST

Combines assessment data with identified nursing diagnoses.
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
Helps cluster data, focuses on nursing diagnoses, assists in validating
nursing diagnosis labels, and combines assessment with problem listing in
one form.

Promotes use by different levels of caregivers, resulting in enhanced
communication among the disciplines.
NURSING MINIMUM DATA SET

Comprises format commonly used in long-term care facilities.

Has a cued format that prompts nurse for specific criteria; usually
computerized.

Includes specialized information, such as cognitive patterns,
communication (hearing and vision) patterns, physical function and
structural patterns, activity patterns, restorative care, and the like.

Meets the needs of multiple data users in the health care system.

Establishes comparability of nursing data across clinical populations,
settings, geographic areas, and time.
6. Discuss the purposes of the client electronic health record (EHR).
a. The EHRs provide nationwide access to client info compiled from data
collected by a variety of health care providers
b. Meaningful use of the EHR implies that electronic documentation will
improve the quality, safety, & efficiency of client care while reducing
disparities.
c. The pt’s & families will be actively engaged in their care & rx through
electronic communication
7. Use SBAR (situation, background, assessment, and recommendation)
method to verbally report client data to another health care provider.
a. SBAR allows:
i. HCT to communicate face to face w/ good eye contact.
ii. Time for the receiver to ask questions
iii. Provide documentation of the data that the nurse is sharing
iv. The nurse must validate what the receiver has heard by
questioning/ asking the receiver to summarize your report
v. When Reporting over a phone, ask the receiver to read back
what they just heard & document the phone call w/ time,
receiver, sender & info shared.
SBAR (SITUATION, BACKGROUND, ASSESSMENT, AND
RECOMMENDATION)
Situation: State concisely why you need to communicate the client data
that you have assessed (example: Mary Lorno, 18 years of age, is
experiencing a sudden onset of periumbilical pain).
Background: Describe the events that led up to the current situation
(example: Client first noticed periumbilical pain at 10:30 AM. She denies any
precipitating factors).
Assessment: State the subjective and objective data you have collected
(example: Subjective: Client rated pain as 7–8 on a scale of 0 to 10 at onset
and now rates the pain as 3–4 on scale of 0 to 10. She denies nausea,
vomiting, and diarrhea. She voices anorexia. Eating and drinking exacerbates
the pain and lying in a knee–chest position diminishes pain. Describes the
pain as “stabbing.” Objective: Client is awake, alert, and oriented. She makes
and maintains conversation. Does not appear to be in acute distress. T—
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98.7, P—72, R—16, BP—112/64. Color pink. Skin warm and dry. Mucous
membranes moist. Abdomen flat without visible pulsations. Bowel sounds
present and hypoactive. Abdomen tympanic upon percussion. Abdomen is
soft. Light palpation reveals minimal tenderness in RLQ. Deep palpation
reveals minimal tenderness in RLQ. Rovsing sign is negative. Obturator sign
is negative. No rebound tenderness noted.)
Recommendation: Suggest what you believe needs to be done for the
client based on your assessment findings (Example: Suggest that the
primary care provider come to further assess the client and intervene).
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