VALIDATING DATA AND SBAR

• Validating of data


  Process of confirming or verifying the subjective and objective data
• The Health Information Technology for Economic and Clinical Health (HITECH) Act was signed into law as part of the American Recovery and Reinvestment Act of 2008 to promote the adoption and meaningful use of health information technology (HIT)

  February 17, 2009
• Purpose of HITECH Act

  1. To eliminate handwritten clinical data and replace it with computer entry data

  2. Constitutes a permanent legal record of the care

  3. Provides access to significant epidemiologic data for future investigations and research

  4. Promotes compliance with legal, accreditation, reimbursement, and professional standard requirements
• Health information


  Data related to an individual's medical history, including symptoms
• Health history


  Comprehensive record of an individual's health over time
• Reports summary


  Consolidates key information from various medical reports
• Progress and session history


  Track a patient's ongoing health developments and therapeutic sessions
• Subjective data


  The nursing interview/ history, consist of the information that the client or significant others tell the nurse
• Objective data


  The physical examination, are what nurse observes through inspections, palpation, percussion or auscultation
• Systematic approaches


  • Head to Toe
  • Major Body Systems
  • Functional Health Patterns
  • Human Response Patterns
• Guidelines for documentation


  • Keep confidential all documented information in the client record
  • Document legibly or print neatly in non-erasable ink
  • Use correct grammar and spelling
  • Avoid wordiness that creates redundancy
  • Use phrases instead of sentences to record data
  • Record data findings, not how they were obtained
  • Write entries objectively without making premature judgments or diagnosis
• Assessment form


  flowcharts to facilitate the recording and retrieval of data
• Verbal communication of data


  Nurses verbally share their subjective and objective assessment findings
• SBAR model of communication


  Developed by the U.S. Navy as a communication technique, introduced to rapid response teams (RRTs) at Kaiser Permanente in Colorado and later adopted by many other health care organizations, most common handover mnemonic models used in health care
• SBAR model


  1. Situation: State why you need to communicate the client data that you have assessed

  2. Background: Describe the events that led up to the current situation

  3. Assessment: State the subjective and objective data you have collected

  4. Recommendation: Suggest what you believe needs to be done for the client base on your assessment findings