VALIDATING DATA

• Validation of data


  The process of confirming or verifying that the subjective and objective data collected are reliable and accurate
• Steps of validation


  1. Deciding whether the data require validation

  2. Determining ways to validate the data

  3. Identifying areas for which data are missing
• Failure to validate data may result in premature closure of the assessment or collection of inaccurate data
• Errors during assessment


  Causes the nurse's judgments to be made unreliable data which results in diagnostic errors during the second part of the nursing process which is the analysis of data
• Validation of the data collected during assessment of the client is crucial to the first step of the nursing process
• Conditions requiring data to be rechecked and validated


  • Discrepancies or gaps between the subjective and objective data
  • Discrepancies or gaps between what the client says at different times
  • Findings that are highly abnormal and/or inconsistent with other findings
• Methods of validation


  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 health care professional

  4. Compare objective findings with subjective findings to uncover discrepancies
• Documentation of assessment data is crucial for effective communication among multidisciplinary health team members to facilitate safe and efficient client care
• Documented assessment data provide the healthcare team with a database that becomes the foundation for care of the client
• Documentation helps identify health problems, formulate nursing diagnoses, and plan interventions
• Information requiring documentation


  • Nursing history and physical assessment (subjective and objective data)
• Subjective data components


  • Biographical data
  • Present health concern(s) and symptoms
  • Personal health history
  • Family history
  • Lifestyle and health practices information
• Objective data components


  • Inspection
  • Palpation
  • Percussion
  • Auscultation
• Document only what the client tells you and what you observe, not what you interpret or infer from the data
• Non-measurable terms to avoid

  • normal
  • abnormal
  • good
  • fair
  • satisfactory
  • poor
• Assessment forms used for documentation

  • Initial assessment form
  • Frequent or ongoing assessment form
  • Focused or specialty area assessment form
• Verbal communication of data

  1. Nurses are often required to verbally share their subjective and objective assessment findings effectively to other healthcare workers

  2. Validation, documentation, and verbal communication of data are crucial aspects of nursing health assessment

  3. Validation of data verifies the assessment data gathered from the client, documentation of data is the act of recording the client assessment findings, nurses need to know how to verbally communicate assessment findings in a clear and concise manner to other healthcare providers
• Data validation


  The process of confirming or verifying that the subjective and objective data collected are reliable and accurate
• Purpose of data validation

  • Decide if data requires validation, determine ways to validate, identify areas where data is missing
  • Failure to validate can result in inaccurate data and diagnostic errors
• Conditions requiring data validation

  • Discrepancies between subjective and objective data
  • Discrepancies in what client says at different times
  • Highly abnormal or inconsistent findings
• Methods of data validation

  1. Recheck own data through repeat assessment

  2. Clarify data by asking client additional questions

  3. Verify data with other healthcare professionals

  4. Compare subjective and objective findings
• Documentation of assessment data


  Recording the assessment findings, crucial part of the nursing process
• Information requiring documentation


  • Nursing history (subjective data)
  • Physical assessment (objective data)
• Subjective data


  • Biographical data
  • Present health concerns and symptoms
  • Personal health history
  • Family history
  • Lifestyle and health practices
• Objective data


  • Inspection
  • Palpation
  • Percussion
  • Auscultation
• Guidelines for documentation


  • Keep confidential
  • Document legibly and neatly
  • Use correct grammar and spelling
  • Avoid wordiness
  • Record data findings, not how obtained
  • Write objectively without premature judgments
  • Record client's understanding
  • Include additional relevant information
• Types of assessment forms

  • Initial assessment (admission database)
  • Frequent/ongoing assessment (flowcharts, progress notes)
  • Focused/specialty area assessment
• Verbal communication of data

  Effectively sharing assessment findings with other healthcare providers, especially during handoffs/handovers
• Validation, documentation, and verbal communication are three crucial aspects of nursing health assessment