Validation and Documentation of Data

• process of confirming or verifying the subjective and objective data you have collected and if they are reliable and accurate

  Validation of Data
• Steps of Validation of Data

  1. Data requiring validation
  2. Methods of validation
  3. Identification of areas for which data are missing
• Data Requiring Validation

  1. Discrepancies or gaps between the subjective and objective data
  2. Discrepancies between what the client says at one time then at another time
  3. Findings that are very abnormal and or inconsistent with the other findings
• METHODS OF VALIDATION OF DATA

  1. Recheck your own data through a repeat assessment
  2. Clarify data with the client by asking additional questions
  3. Verify the data with another healthcare professional
  4. Compare your objective findings to uncover discrepancies
• Once the initial data base is established, identify areas for which more data are needed
• Is an important step of assessment because it forms the database for the entire nursing process and provides data for all other members of the health care team


  DOCUMENTING DATA
• It is anything written or printed on which you rely as record or proof of patient actions and activities

  Documentation
• Comprised of medical notes made by a physician, nurse, lab technician or any other member of a patient’s healthcare team.

  RECORD/CHART
• Accurate and complete medical charts ensure systematic documentation of a patient’s medical history, diagnosis, treatment, and care
• A permanent record of client’s information

  charting
• Types of Charting

  1. Narrative Charting
  2. Source Oriented Charting
  3. Problem Oriented Charting
  4. SOAP/IE/R Charting
  5. Focus Charting (FDAR)
  6. SBAR Charting
• Narrative Charting- Charting in a story format

  
• Source Oriented Charting- It requires documentation of patient’s care in chronological order

  
• Promotes problem solving approach

  A) Problem Oriented Medical Report

  
• give the meaning of the acronym SOAP/IE/R

  Subjective

  Objective

  Assessment

  Planning

  Intervention

  Evaluation

  (R)evision
• PIE Problem

  A) problem

  B) intervention

  C) evaluation

  
• Focus Charting (FDAR)

  A) Data

  B) Action

  C) Response

  D) Focus

  
• SBAR Charting

  A) situation

  B) background

  C) assessment

  D) recommendation

  
• Initial Assessment Form

  1. Open Ended Forms
  2. Cued/Checklist Forms
  3. Integrated Cued Forms
  4. Nursing Minimum Data Set
• Open Ended Forms

  
• Cued/Checklist Forms

  
• Integrated Cued Checklist

  
• Nursing Minimum Data Set

  
• FREQUENT/ONGOING ASSESSMENT FORM- help staff record/ retrieve data for frequent assessment

  
• FOCUSED/SPECIALTY AREA ASSESSMENT FORM- focused on one major area of the body for clients who have a particular problem

  
• COMPUTERIZED DOCUMENTATION

  1. ELECTRONIC HEALTH RECORDS (EHRs)- Used to manage the huge volume of information required in contemporary health care
• Kardex- series of cards kept in a portable index file

  
• Flow Sheets- a graphic record

  
• NURSING DISCHARGE/REFERRAL SUMMARIES- completed when the client is being discharged and transferred to another institution or to a home setting where a visit by a community health nurse is required.

  
• 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