Chapter 4: Validating And
Documenting Data
Validating Data: process of checking that
the subjective and objective data
collected are reliable and precise. crucial
to the first step of the nursing process.
Documenting Assessment Data
Documenting assessment data is essential because it fulfills the first step of
the nursing process: assessment. This involves collecting holistic subjective
and objective data about the patient. Accurate documentation of this data
provides a baseline for making informed clinical judgments. It also fosters
effective communication among the healthcare team, ensuring coordinated
and efficient care. Furthermore, well constructed documentation helps in
continuous monitoring of the patient's health status, supports legal and
financial requirements, and promotes compliance with professional
standards. By documenting assessment data, nurses ensure they have a
reliable basis for all subsequent phases of the nursing process, ultimately
enhancing the quality of patient care.
Data Requiring Validation:
Inconsistencies between the subjective and objective
data. For example, a female client tells you that she is
fine but was just diagnosed with parkinsons disease.
Inconsistencies between what the client says at one
time versus another time. For example, your female
client says that she has never had surgery, but later in the
interview, she mentions that she had her kidney removed.
Findings that are extremely abnormal and/or
inconsistent with other findings. For example, findings
are inconsistent with each other: the client has a
temperature of 120°F, is resting peacefully, and their skin
is warm and not feverish.
Guidelines For Documentation
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Methods Of Validation:
Recheck data through a repeat assessment.
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Keep confidential documented information in the client record
Document legibly or print neatly in nonerasable ink
Use only abbreviations that are acceptable and approved by the
institution
Avoid words that are redundant
Use phrases not sentences to record data
Record data findings, not how they were obtained.
Write entries objectively without making assumptions or
diagnoses.
Record the client’s understanding and perception of problems
Avoid recording the word “normal” for normal findings(Also
avoid using the terms good, fair, poor, sometimes, occasional,
frequently, recently, or some)
Record complete information and details for all client symptoms
or experiences.
Include additional assessment content when it applies
Support objective data with certain observations obtained during
the physical exam.
Clarify data with the client by asking more
questions.
Verify data with another health care provider
Compare your objective findings with your
subjective findings to uncover gaps.
Assessment Forms Used for Documentation
Initial Assessment
Form
Frequent/Ongoing
Assessment Form
Focused/Specialty
Area Assessment
Form
Flowchart that helps
staff with recording and
retrieving data
Focused on one area of
concern/particular
problem
Easy depiction of
abnormalities and
comparison across time.
Quality not quantity of
documentation
admission data sheets
abbreviated
"For Nursing
admission or
admission database"
S-State exactly why you need to communicate the client data
assessed
B-Describe the occasions that led up to the current situation
A- State the subjective and objective data collected
R- Suggest what you believe needs to be done for the client
based on your assessment finding
How the Nurse prepares oneself to assess patient
Review the patient's medical records and prepare necessary equipment.
Understand the patient's medical history, chronic conditions, and cultural background.
Gather comprehensive subjective and objective data through health history interviews and
physical exams. Then validate the data.
Analyze data to identify health problems, plan interventions, and communicate findings to
the healthcare team
Open-ended (narrative
description, total picture,
not standardized)
Cued/Checklist (easy
documentation,commen
t, might not contain area
of concern,and
standardized)
Integrated Cued Checklist
(clusters data, focuses on
client concerns, simple
validation, advances
communication)
Nursing Minimum Data
Set (utilized in LTCF,
specific criteria, meets
needs of multiple data
users, establishes
comparability of data)