Validation and Documentation of Data

• Methods of Validation of Data

  • Rechecking own data through repeat assessment
  • Clarifying data with the client by asking additional questions
  • Verifying data with another healthcare professional
  • Comparing objective findings to uncover discrepancies
• Documenting Data

  Important step in assessment forming the database for the nursing process and providing data for the healthcare team
• Purposes of Record/Chart

  • Communication
  • Legal documentation
  • Research
  • Statistics
  • Education
  • Audit and quality assurance
  • Planning client care
  • Reimbursement
• Steps of Validation of Data


  1. Data requiring validation

  2. Methods of validation

  3. Identification of areas for which data are missing
• Vague Documentation

  • Memory Intact
  • Vital signs good
  • Skin color normal
  • Appetite good
  • Swelling of ankles
  • Voids a lot
• Charting

  Methods of documentation
• Validation of Data

  Confirming or verifying the subjective and objective data collected for reliability and accuracy
• Data Requiring Validation

  • Discrepancies or gaps between subjective and objective data
  • Discrepancies in client statements over time
  • Findings that are very abnormal or inconsistent with other findings
• Elements of Effective Documentation

  • Uses of common vocabulary
  • Legibility
  • Abbreviations and symbols
  • Organization
  • Accuracy
  • Documenting a medication error
  • Confidentiality
  • Factual
  • Complete
  • Current organized
• Identification of Areas for Which Data are Missing

  • Identifying areas needing more data after establishing the initial database
  • Examining data in a grouped format
• Assessment Forms Used for Documentation

  1. Initial assessment forms

  2. Frequent/ongoing assessment form

  3. Focused/specialty area assessment form
• Record/Chart

  Comprised of medical notes by healthcare team members, ensuring systematic documentation of a patient's medical history, diagnosis, treatment, and care
• Clear and Concise Documentation

  • Recent and remote memory intact
  • Temperature: 37.2°C; PR 66; RR 18; BP 120/80
  • Skin pink with consistent pigmentation
  • Reports no change in appetite
  • Pitting edema 3+ of both ankles that lasts 10 seconds
  • Polyuria, urinary output = 3000 mL/day
• SOAPIE charting


  Subjective, Objective, Assessment, Planning, Intervention, Evaluation
• Problem oriented medical report


  Focuses on the client's problem itself, promotes problem-solving approach, improves continuity of care and communication by charting relevant data
• PIE charting

  Problem, Intervention, Evaluation
• Narrative charting


  Charting in a story format, mostly in one paragraph, similar to a short story
• SBAR charting


  Subjective, Background, Assessment, Recommendation
• Note with call referrals: '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. Remember if it is not recorded, it has not been done'
• EHRs make care planning and documentation relatively easy and allow for information transmission between care settings
• EHRs can integrate all pertinent client information into one record
• Methods of documentation

  1. Narrative charting

  2. Source oriented charting

  3. Problem oriented charting

  4. SOAPIE/IER charting

  5. Focus charting

  6. SBAR
• SOAPIER charting


  Subjective, Objective, Assessment, Planning, Intervention, Evaluation, Revision
• SOAP charting


  Subjective, Objective, Assessment, Planning
• Nurse's responsibilities with EHRs include storing client's database, adding new data, creating and revising care plans, and documenting client progress
• Other forms of documentation

  • Kardex
  • Flow sheets
  • Nursing discharge/referral summaries
• Source oriented charting


  Documentation of patient's care in chronological order
• Electronic Health Records (EHRs) are used to manage the huge volume of information required in contemporary health care
• Focus charting

  Focus Problem, Data, Action, Response