VALIDATING

• PURPOSE OF VALIDATION

  • Validation of data is the process of confirming or verifying that the subjective and objective data you have collected are reliable and accurate.
• Steps of Validation

  1. Deciding whether the data require validation :
  2. Determine ways to validate data
  3. Identifying areas for which data are missing
• Data Requiring Validation

  • Conditions that require data to be rechecked and validated include:

  1. Discrepancies or gaps between subjective and objective data.
  2. Discrepancies or gaps between what the client says at one time versus another time.
  3. Finding that are highly abnormal and/or inconsistent with other findings.
• 1. METHODS OF VALIDATION
  2. Recheck your own data through a repeat assessment.
  3. Clarify data with the client by asking additiona questions.
  4. Verify the data with another health care professional.
  5. Compare your objective findings with your subjective findings to uncover discrepancies.
• Communication

  A dynamic, continuous, and multidimensional process for sharing information
• Documentation as Communication

  • Nurses rely on charting, records, and systems that support the implementation of the nursing
  • process.Systematic documentation is critical to presenting the care administered by nurses in a logical fashion.Critical thinking skills, judgments, and evaluation must be clearly communicated through proper documentation.
• Major communication techniques used by healthcare

  • Reporting
  • Recording
• Medical record

  A legal document for recording all client activities by health care practitioners
• Documentation


  Written evidence of:

  • The interactions between and among health professionals, clients, their families, and health care organizations
  • The administration of tests, procedures, treatments, and client education
  • The results or client's response to these diagnostic tests and interventions
• Purposes of Health Care Documentation

  • Professional Responsibility and AccountabilityEducation -
  • Communication
  • Research
  • Legal and Practice Standards
  • Recording provides written evidence of what was done for the client, the client's response, and any revisions made in the care plan.
  • Recording documents compliance with professional practice standards and accreditation criteria.
  • Written records are a resource for review, audit, reimbursement, and research.
  • Documentation provides a written legal record to protect the client, institution and practitioner.
• • EDUCATION
  • Health care students use the medical record as a tool to learn about disease processes, diagnoses, complications, and interventions.Clinical rounds and case conferences rely heavily on information contained in the medical record.
• Research

  • Researchers rely heavily on medical records as a source of clinical data.Documentation can validate the need for research.
• • Legal and Practice Standards
  • In 80% to 85% of malpractice lawsuits involving client care, the medical record is the determining factor in providing proof of significant events.
  • Informed ConsentAdvance DirectivesAmerican Nurses Association (ANA) Standards of CareState Nurse Practice ActsJoint Commission on Accreditation of Health CareOrganizations (JCAHO)
• Principles of Effective Documentation

  • Nursing notes must be logical, focused, and relevant to care, and must represent each phase of the nursing process.
  • Nursing documentation based on the nursing process facilitates effective care.
• Elements of Effective Documentation

  1. use of common vocabulary
  2. legibility
  3. Abbreviations and Symbols
  4. organization
  5. accuracy
• Documenting a Medication Error

  Adminstration Record) he MAX (Medication

  • Document in the nurses progress notes:

  • Name and dosage of the medication

  Name of the practitioner who was notified of the error

  Time of the notification

  Nursing interventions or medical treatment

  • Client's response to treatment
• Narrative Charting

  • Describes the client's status, interventions and treatments; response to treatments in story format.
  • CHRONOLOGICAL d by other formats.
  • LENGTHY,
  • ENG THY TIME CONSUMING
  • SOURCE-ORIENTED
• Source-Oriented Charting

  Narrative recording by each member (source) of the health care team on separate records.
• Problem-Oriented Charting (POMR)

  • Uses a structured, logical format called S.O.A.P.
  • S: subjective data

  0: objective data

  • A: assessment (conclusion stated in form of nursing diagnoses or client problems)
  • P: planUses flow sheets to record routine care.
  • SOAP entries are usually made at least every 24 hours on any unresolved problem.

  SOAP was developed on a medical model.
• SOAPIE and SOAPIER refer to formats that add:

  1. Intervention
  2. Evaluation
  3. revisions
• SOURCE-Oriented Charting

  • pie charting
  • P: Problem
  • I: Intervention
  • E: Evaluation
  • Key components are assessment flow sheets and

  the nurses' progress notes with an integrated plan of

  • PiE charting is a nursing model
• Focus Charting

  • narrative documentation of all dient Concerns

  • Includes data, action, responseUses a columnar format within the progress notes to distinguish the entry from other recordings in the narrative notes.
• USES NARRATIVE DOCUMENTATION (DAR)

  • DATA - SUBJECTIVE OR OBJECTIVE THAT SUPPORTS THE FOCUS (CONCERN)
  • ACTION - NURSING INTERVENTION
  • RESPONSE - PT RESPONSE TO INTERVENTION
• Charting by Exception (CBE)

  • The nurse documents only deviations from pre-established norms.
  • avoid lengthy notes
• COMPUTERIZED DOCUMENTATION

  • Increases the Documentation and save
  • Increases legibility and accuracy.
  • Enhances implementation of the nursing process.
  • Enhances the systematic approach to client care.
  • Provides clear, decisive, and concise key words standardized nursing terminology).
  • Provides access to other data, enhancing critical thinking.
  • Information is quickly coordinated and integrated by other departments.
  • Facilitates statistical analysis of data.
• PASSWORD. NEVER SHARE. CHANGE FREQUENTLY.

  CAN BE VOICE-ACTIVATED, TOUCH-ACTIVATED.

  DATE AND TIME AUTOMATICALLY RECORDED.

  ABBREVIATIONS AND TERMS ARE SELECTED BY A MENU

  TERMINALS ARE USUALLY EASILY ACCESSIBLE, IN PT ROOMS, CONVENIENT HALLWAY LOCATIONS.

  * MAKE SURE TERMINAL CANNOT BE VIEWED BY UNAUTHORIZED PERSONS.
• Point-of-Care System

  • A handheld portable computer is used for inputting

  • Provides each hath care practitioner with all pertinent client data to ensure continuity of care without duplication

  • Provides crucial client information in a timely fashion,
• Forms for Recording Data

  • Kardex
  • Flow sheets
  • Nurses progress Notes
  • Discharge Summary
• Kardex


  Used as a QUICK reference throughout the shift and during change-of-shift rental data
• Information in Kardex

  • Medical diagnoses
  • Nursing diagnoses
  • Medical orders (Carried Out and Pending)
  • Activities
• Information in Kardex is NOT PART OF PERMANENT RECORD
• Flowsheets


  • Reduce the redundancy of charting
  • Information on flow sheets can be formatted to meet the specific needs of the client
• Nurses Progress Notes


  • Used to document the client's condition, problems, and complaints, interventions, responses, and achievement of outcomes
  • Can be completely narrative or incorporated into a standardized flow sheet
• Discharge Summary


  • Client's status at admission
  • Client's status at discharge
  • Brief summary of client's care
  • Interventions and education outcomes
  • Client instructions
  • Referrals
  • Resolved problems and continuing need
• Trends in Documentation

  • Standardized data bases are required to ensure accuracy and precision in nursing information
• Reporting


  Verbal communication of data regarding the client's health status, needs, treatments, outcomes, and responses
• Reporting

  Summary of current critical information to facilitate clinical decision making and continuity of client care
• Reporting


  • Based on the nursing process standards of care, and legal and ethical principles
  • Requires participation from everyone present
• Summary Reports

  1. Commonly occur at change of shift (or when client is transferred)

  2. Include assessment data

  3. Include primary medical and nursing diagnoses

  4. Include recent changes in condition, adjustments in plan of care, and progress toward expected outcomes
• Walking Rounds


  1. Nursing, physician interdisciplinary

  2. Occur in the client's room

  3. Include the client