NCM 101 - 2

• Subjective data - are sensations or symptoms (pain, hunger,) feelings, happiness, sadness, perceptions, desires, preferences, beliefs, ideas, values, and personal information that can be elicited and verified only by the client.
• Interview - Method of subjective data
• Objective data - Observations noted by the family or significant others about the client
• Validating Assessment Data - Serves to ensure that the assessment process is not ended before all relevant data have been collected and helps to prevent documentation of inaccurate data
• Documenting Data - It forms the database for the entire nursing process and provides data for all other members of the healthcare team
• Documenting Data - Thorough and accurate documentation is vital to ensure that valid conclusions are made when the data are analyzed
• Interview - Establishing rapport and trusting relationship with the client to elicit accurate and meaningful information
• Interview - Gathering information on the client’s developmental, psychological, physiological, sociocultural, and spiritual status to identify deviations that can be treated with nursing and collaborative interventions or strengths that can be enhanced through nurse-client collaboration
• Preintroductory phase - The nurse reviews the medical records before meeting the client
• Preintroductory phase - Know past health history and reason for seeking health care
• Introductory Phase - The nurse explains the purpose of the interview
• Introductory Phase - Discusses the types of questions that will be asked
• Introductory Phase - Explains the reason for taking notes
• Introductory Phase - Assures the client that confidential information will remain confidential
• Introductory Phase - Make sure that the client is comfortable ( physically and emotionally) has privacy interviewing at eye level, Trust and rapport
• Working phase - Client’s comments about major biographical data, reasons for seeking care, history of the present condition, past health history, family history, review of body systems for current health problems, lifestyle and health practices, and developmental level.
• Working Phase - the nurse listens, observes cues, and uses critical thinking skills to interpret and validate information received from the client
• Working Phase - The nurse and client collaborate to identify the client’s problems and goals
• Summary and closing phase - The  nurse summarizes information obtained during the working phase and validates problems and goals with the client
• Summary and Closing Phase - Identifies and discusses possible plans to resolve the problem (client concerns and collaborative problems)