Health Assessment in Nursing: Validating and Documenting Data

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Validation of Data
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confirming/verifying subjective and objective data collected are reliable and accurate
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Steps of Validation
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1) deciding whether the data require validation 2) determining ways to validate the data 3) identifying areas where data are missing
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Ways to Validate Data
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1) recheck your data via repeat assessment 2) clarify data with client by asking addtl questions 3) verify data with another health care professional 4) compare objective findings with subjective findings to uncover discrepancies
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Primary Reason for Documenting Initial Assessment
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provides health care team w/ database that becomes foundation for care of client; helps to: – identify health problems – formulate nursing diagnoses – plan immediate and ongoing interventions
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Importance of Initial and Ongoing Assessment Documentation Database
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establishes a way to communicate w/ multidisciplinary team members
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Two Key Elements to be Included in Documentation
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1) nursing history 2) physical assessment
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Objective Data – Four Key Elements
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1) inspection 2) palpation 3) percussion 4) auscultation
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Primary Purpose of Objective Data
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1) further define client’s problem(s) 2) establish baseline data 3) validate subjective data
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Objective Data – Systematic Approaches
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1) head-to-toe 2) major body systems 3) functional health patterns 4) human response patters
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Assessment Forms Commonly Used to Document Data
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1) initial assessment form 2) frequent or ongoing assessment form 3) focused or specialized assessment form
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Two Crucial Aspects of Nursing Assessment
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1) validation 2) documentation
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Focused or Specialty Area Assessment Form
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focus on one major area of the body for clients who have a particular problem (i.e. cardiovascular or neurologic)
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Initial Assessment Form
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called nursing admission or admission database types frequently used: 1) open-ended 2) cued or checklist 3) integrated cued checklist 4) nursing minimum data set (NMDS)
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Frequent or Ongoing Assessment Form
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flow charts designed to help staff record/retrieve data for frequent reassessments examples: frequent vital signs sheet and assessment flow chart
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Progress Notes
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part of the frequent/ongoing assessment used to document unusual events, responses, significant observations, or interactions because data are inappropriate for flow records

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