Collecting and Validating Data

Why must the nurse validate assessment data?

Validation helps prevent inaccurate information from becoming part of the client's assessment database.

What are the four methods the nurse can use to validate assessment data?

Repeat the assessment, ask additional questions, verify the information with another healthcare professional, and compare objective findings with subjective findings.

When should assessment data be validated?

When there are discrepancies or gaps in the data, conflicting client statements, or abnormal or inconsistent findings.

How can the nurse validate a questionable physical assessment finding?

Repeat the assessment.

How can the nurse validate incomplete or unclear subjective information?

Ask the client additional questions.

How can another healthcare professional help validate data?

The nurse can compare or verify assessment findings with information obtained by another healthcare professional.

How can subjective and objective data be used together for validation?

Compare what the client reports with what the nurse observes or measures to determine whether the findings are consistent.

A client reports having an elevated temperature but shows no signs of fever. What should the nurse do?

Validate the data because the subjective report and objective findings are inconsistent.

A client's temperature is 104°F, but the client is resting comfortably and is not flushed. What should the nurse do?

Validate the abnormal or inconsistent finding before accepting it as accurate.

What is the primary reason for documenting assessment data?

To provide effective multidisciplinary communication that facilitates safe and effective client care.

What does documentation create?

A database containing information about the client's health and care.

What benefit can electronic documentation provide?

Electronic documentation can link client health information and improve accessibility and collaboration.

How are EMRs described in the notes?

Medical records supplied by physicians.

How are EHRs described in the notes?

More comprehensive records of health status that reach beyond one healthcare organization.

What is a legal purpose of nursing documentation?

It creates a permanent legal record of care that was given or not given.

How can documented health information be used beyond direct client care?

It can provide epidemiologic and research data.

What standards can proper documentation help healthcare organizations meet?

Legal, accreditation, reimbursement, and professional standards.

What are the two key elements documented during health assessment?

The nursing interview/health history containing subjective data and the physical assessment containing objective data.

When should the nurse document assessment findings?

Make notes as the assessment is completed.

How should nursing documentation be written?

It should be concise, specific, descriptive, and measurable.

What type of wording should be avoided in documentation?

General, non-descriptive, and non-measurable wording.

Why should the nurse avoid documenting a finding simply as "normal"?

The nurse should document the specific observation or exact value rather than using a vague description.

How should symptoms be documented?

Document complete information describing the symptom.

What should the nurse document about the client's understanding and perceptions?

The client's understanding and perceptions should be included when relevant to the assessment.

How should objective assessment findings be documented?

Use specific observations and measurable findings.

What confidentiality principle applies to client documentation?

Client information should remain confidential and be accessed or shared only on a need-to-know basis.

What law protects the confidentiality of client health information?

HIPAA.

What writing standards should the nurse follow when documenting?

Documentation should be legible and use correct grammar, spelling, and approved abbreviations.

Which abbreviations for subcutaneous should NOT be used according to the notes?

SC, SQ, sq, and sub q.

How should "subcutaneous" be documented?

Write out "subcutaneous" or "subcutaneously."

Why should redundancy be avoided in documentation?

Documentation should remain concise while still communicating the necessary information.

What is a handoff?

Verbal communication of essential client information whenever responsibility for care is transferred.

When is a handoff required?

During events such as shift change, transfer to another unit, or when the client leaves for a test or procedure.

What standardized communication format is identified in the notes for handoff communication?

SBAR.

What does SBAR stand for?

Situation → Background → Assessment → Recommendation.

What information is included in the Situation portion of SBAR?

A concise statement explaining why the nurse is communicating about the client.

What information is included in the Background portion of SBAR?

A description of the background and current situation relevant to the client's condition.

What information is included in the Assessment portion of SBAR?

Relevant subjective and objective assessment data.

What information is included in the Recommendation portion of SBAR?

The nurse's suggestion about what needs to be done.

A nurse begins a report by stating why they are calling about the client. Which SBAR component is this?

Situation.

A nurse provides relevant information about the client's current situation and history. Which SBAR component is this?

Background.

A nurse reports the client's subjective complaints and objective findings. Which SBAR component is this?

Assessment.

A nurse states what action they believe should occur next. Which SBAR component is this?

Recommendation.

How should handoff communication be performed according to the notes?

Use a standardized format such as SBAR, communicate face-to-face when possible, allow questions and clarification, and provide appropriate documentation.

How can the receiving nurse validate information during a handoff?

Ask questions and summarize the information received.

Why should the receiving nurse have an opportunity to ask questions during handoff?

To clarify and validate the information being transferred.