VALIDATION OF DATA, DOCUMENTATION OF DATA At the end of this unit, the students are expected to: Cognitive: 1. Describe the significance and process for validation of client data. 2. Discuss the situations that require client data to be rechecked or verified. 3. Describe the multiple purposes of accurate and timely documentation of client data. 4. Identify safe guidelines for documentation of client data. 5. Use SBAR (situation, background, assessment, and recommendation) method to verbally report client data to another health care provider. Affective: 1. Inculcate that the assessment phase is the most important phase of the nursing process. An effective nursing care plan contains an accurate assessment. 2. Listen attentively during class discussions 3. Demonstrate tact and respect when challenging other people’s opinions and ideas 4. Accept comments and reactions of classmates on one’s opinions openly and graciously. Psychomotor: 1. Participate actively during class discussions 2. Confidently express personal opinion and thoughts in front of the class during online. VALIDATING DATA Purpose of Validation • Is the process of confirming or verifying that the subjective and objective data the nurse have collected are reliable and accurate • The steps of validation include: o Data Requiring Validation ▪ Conditions that require data to be rechecked and validated include: • Discrepancies or gaps between the subjective and objective data • Discrepancies or gaps between the client says at one time versus another time • Findings that are highly abnormal and/or inconsistent with other findings o Methods of Validation ▪ There are several ways to validate your data: • Recheck your own data through a repeat assessment • Clarify with the client by asking additional questions • Verify the data with another health care professional • Compare your objective findings with your subjective findings to uncover discrepancies o Identification of Areas for Which Data are Missing ▪ Once an initial database is established, identify areas for which more data are needed ▪ Examine data in a grouped format DOCUMENTING DATA • another crucial part of the first step in the nursing process • categories of information on the forms are designed to ensure that the nurse gathers pertinent information needed to meet the standards and guidelines of the specific institutions mentioned previously and to develop a plan of care for the client Purpose of Documentation • Promote effective communication among multidisciplinary health team members to facilitate safe and efficient client care • Provides the health care team with a database that becomes the foundation for care of the client • Helps to identify health problems, formulate nursing diagnoses, and plan immediate and ongoing interventions • The use of electronic health records (EHRs) also increases the likelihood that clients received life-saving treatments and may lower the risk of hospital acquired infections Things to Consider on Documentation • Legal record of patient encounter • May be used by many professionals • Document in a professional and legally acceptable manner • FOLLOW INSTITUTION’S SYSTEM • Ensure accuracy • Ensure correct patient record or chart o Record information immediately upon completion of patient encounter o Avoid distractions while documenting o Date and time each entry Guidelines for Documentation • Keep confidential all documented information in the client record • Document legibly or print neatly in nonerasable 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 diagnoses • Record the client’s understanding and perception of problems • Avoid recording the word “normal” for normal findings • Record complete information and details for all client symptoms or experiences • Include additional assessment content when applicable • Support objective data with specific observations obtained during the physical examination Assessment Specific Documentation Guidelines • Record pertinent positive and negative assessment data • Document any parts of the assessment that are omitted or refused by patient • Avoid using judgmental language • Avoid evaluative statements; cite specific statements or actions you observe • State time intervals precisely • Use specific measurements • Draw pictures when appropriate • Refer to findings using anatomic landmarks • Use the face of a clock to describe findings that are in a circular pattern • Document any change in patient’s condition during a visit or from previous visits • Describe what you observed, not what you did Examples of Vague versus Clear and Concise Documentation of Data Vague Documentation Memory intact Vital signs good Skin color normal Appetite good Reports no change in appetite Swelling of ankles Voids a lot Clear and Concise Documentation Recent and remote memory intact Temperature: 37.2OC; 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 CHARTING • the common term used in the field of nursing when it comes to documentation Purpose of Charting • It is a permanent record of patient’s information. • Tracks the progress of the patient’s condition during the hospitalization as well as the status upon discharge. It serves as an information sheet of the medications and procedures rendered to the patient. • Legal evidence for cross-examination whenever complaints or malpractice claims have been sighted out. • It serves as the evidence of continuity of care. • It serves as a research material for retrospective study. Types of Charting • Narrative Charting o traditional form of charting o source-oriented record o advantage is that it provides organized section for each member of the healthcare team o disadvantage in using this type of recording is that the information is scattered throughout the chart o Example: ▪ Treatment Chart ▪ Admission sheet ▪ Initial Nursing Assessment ▪ Graphic Record • Problem-oriented record o give focus on the problems that patients face o each medical personnel can contribute and collaborate on the plan of care o advantage seen in this type of charting is collaboration among medical personnel o the disadvantage here is that it takes complete and on time assessment of problem lists • SOAP formats o usually used since it gives a quick look at the observation of each nurse as well as the nursing action on each observation. ▪ S – Subjective data includes the patient’s complaints or perception of the present problem sited. ▪ O – Objective data includes the nurse’s observation using his or her clinical eye ▪ A – Assessment includes the inference made by the nurse from the two types of data. This is the part wherein the problem is stated. The nursing problem is stated in a form of nursing diagnoses using the NANDA. ▪ P – Plan this includes the nursing actions to be made in order to solve the stated problem. This part can be revised. o Additional entries ▪ SOAPIE or SOAPIER • I – Intervention –This is the part wherein specific nursing actions are stated • E – Evaluation –This is the part wherein the nurse evaluates the reaction of the patient or progress of the problem being solved. • R-Revision – This is the section that states the changes made in order to further resolve the problem. o Example: ▪ Case: A patient with hypersensitivity reaction secondary to food intake. •S o “My skin is so itchy, especially on the skinfolds.” •O o Skin appears to be flushed with bumps. Irritation noted on the armpit and inner thighs. •A o Altered comfort secondary to food intake •P o Inform the patient not to scratch the skin. o Apply cold compress on the hot spots o Cut nails in order to prevent skin scratches o Refer to the physician o Assess for progress of skin rash •I o Instructed not to scratch the skin. o Cut the fingernails short o Applied cold compress o Referred to the physician •E o “I feel more comfortable and I do not have the urge to scratch my skin.” •R o Give antihistamine (Antamin) 1mg/mL as deep intramuscular injection to left deltoid muscle. • Focus Charting (FDAR) o This type of charting involves Data, Action and Response category. o This is a client-focused charting o Since it the client being talked about most of the documentation, this is a form of holistic perspective of client’s needs. o Example ▪ F (Focus) • Nursing Dx, Client Concern, S&S, Event ▪ D (Data) • Facial grimacing, graded the nape pain as 7 in the scale of 1 to 10 with 10 as severe pain ▪ A (Action) • Given Norgesic Forte per orem as now dose. ▪ R (Response) • Rated pain as 2 and able to walk on her own. • The SBAR o Situation, Background, Assessment, Recommendation o a model of communication o one of the most common handover mnemonic models used in health care o improve quality and patient safety outcomes when used by health team members to communicate or hand-off client information Assessment Forms Used for Documentation • Initial Assessment Form o Is called a nursing admission or admission database o 4 types 1. Open – Ended Forms (Traditional form) 2. Cued or Checklist Forms 3. Integrated Cued Checklist 4. Nursing Minimum Data Set • Frequent or Ongoing Assessment Form o Flowcharts that help staff record and retrieve data for frequent reassessments o Examples ▪ Vital signs sheet ▪ Assessment flowchart o Emphasis is placed on quality, not quantity of documentation • Focused or Specialty Area Assessment Form o Focused on one major area of the body for clients who have a particular problem o Examples ▪ Cardiovascular assessment forms ▪ Neurologic assessment forms Computerized Documentation Electronic Health Records (EHRs) • Used to manage the huge volume of information required in contemporary health care • Can integrate all pertinent client information into one record • Nurse’s responsibilities include storing client’s database, add new data, create and revise care plans and document client progress • Makes care planning and documentation relatively easy • Transmit information from one care setting to another Other Forms of Documentation Kardex • Widely used, concise method of organizing and recording data about a client, making information accessible to all health professionals • Consists of series of cards kept in a portable index file which is particular for a client • Can be quickly accessed to reveal specific data • May or may not become a part of the client’s permanent record Flow sheets • Graphic Record • Intake and Output Record • Medication Administration Record (MAR) • Skin Assessment 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 Suggested Readings: D’Amico, D., and Barbarito, C., (2019) Health & Physical Assessment in Nursing 3rd Edition, Singapore: Pearson Education, Inc. https://www.slideshare.net/Bates2ndQuarterLPN/nursing-skills-charting https://www.rch.org.au/rchcpg/hospital_clinical_guideline_index/nursing-documentation-principles/ http://www.nursingworld.org/~4af4f2/globalassets/docs/ana/ethics/principles-ofnursingdocumentation.p References Weber, J.R., and Kelley, J. H., (2018) Health Assessment in Nursing 6th Edition, Philadelphia: Wolters Kluwer https://rnspeak.com/charting-for-nurses/ Berman, A.; Snyder S.J.; Frandsen, G.; (2016) Fundamentals of Nursing, 10th Edition, Harlow, England, Pearson Education *Kozier, Fundamentals of Nursing, 8th Edition Hinkle, J.L., and Cheever, K.H., (2018) Brunner & Suddarth’s Textbook of Medical – Surgical Nursing, 14th Edition, Philadelphia: Wolters Kluwer D’Amico, D., and Barbarito, C., (2019) Health & Physical Assessment in Nursing 3rd Edition, Singapore: Pearson Education, Inc. Prepared by: Purisima M. Nocos, BSM, RM, RN, MAN Course NCM 011 Professor 2nd Semester 2022
