Health Asses Part 5

Purpose of Assessment Documentation

Provides a chronologic source of patient assessment data.

Subjective vs

Comparison helps in the validation of data.

Significance of Documentation

Plays a role in compliance with Joint Commission and Medicare.

Accurate Documentation

"Skin pale, warm, and dry without evidence of lesions."

Nursing Minimum Data Set

Most likely used in a long-term care facility.

Documenting Patient History

"Patient denies prior hospitalizations and surgeries."

Validating Data

Checking findings with another health care professional is reliable.

Assessment Form in Neurology

Ongoing assessment form is most likely used.

Purpose of Documentation

Provides a permanent legal record of care given and not given.

SBAR Format

"What would you like to do to address this patient's nausea?"

Validating New Orders

Read the order back to the surgeon for confirmation.

Preventing Handoff Errors

Encourage thorough and clear handoff reports.

Validating Subjective Pain Complaint

Perform further assessments addressing various aspects of the patient's pain.

Warranting Validation

"The patient states, 'My skin's kind of yellow because of my liver.'"

HITECH Act Compliance

Increase the use of electronic health records (EHRs) in the hospital.

Need for Further Data

The man has a diffuse rash on his torso.

Advantages of EHRs

Improved continuity of care.

Documenting Objective Findings

"Area of nonblanching erythema noted over patient's coccyx, 2 cm × 2 cm."

HIPAA Compliance

Maintaining the privacy and confidentiality of patients' medical records.

Data Analysis Results

Nursing diagnoses are a direct result of data analysis.

Challenge of Data Analysis

It requires sophisticated diagnostic reasoning skills.

Critical Thinking in Nursing

Involves reflections on thoughts before reaching conclusions.

Data Validation

Validate the collected data before proceeding with analysis.

Identifying Abnormal Data

Knowledge of anatomy and physiology is essential.

Useful Data for Risk Nursing Diagnosis

The patient is separated from her usual social supports.

Patient's State of Harmony

This prompts the identification of a health promotion diagnosis.