Validation & Documentation of Data
NCMA 111 - WEEK # 3 - LEC
VALIDATION & DOCUMENTATION OF DATA
VALIDATING OF DATA
TOPIC OUTLINE
I. INTRODUCTION
II. STEPS OF VALIDATION
III. ASSESSMENT SPECIFIC DOCUMENTATION
GUIDELINES
I. INTRODUCTION
Validation
▪ It is the act of double checking or verifying data to
confirm that they are accurate & factual.
▪ The information gathered during the assessment phase
must be complete because the nursing diagnosis &
planning goals & desired outcomes, interventions are
based on this information.
Validating Data
▪ Purpose of Validation – it is the process of confirming or
verifying that the subjective and objective data the nurse
have collected are reliable & accurate.
II. STEPS OF VALIDATION
Data Requiring Validation
▪ Conditions that require data to be rechecked & validated:
• Discrepancies or gaps between the subjective &
objective data.
• Discrepancies or gaps between the client says at
one time versus another time.
• Findings that are highly abnormal &/or inconsistent
with other findings.
III. ASSESSMENT SPECIFIC DOCUMENTATION GUIDELINES
Methods of Validation
▪ 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.
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.
DOCUMENTATION OF FINDINGS
TOPIC OUTLINE
I. INTRODUCTION
II. PURPOSES OF DOCUMENTATION
III. PURPOSES OF ASSESSMENT DOCUMENTATION
IV. THINGS TO CONSIDER IN DOCUMENTATION
V. GUIDELINES FOR DOCUMENTATION
VI. ASSESSMENT SPECIFIC DOCUMENTATION
GUIDELINES
VII. VAGUE VS. CLEAR & CONCISE DOCUMENTATION
VIII. PATIENT’S RECORD
IX. CHARTING OR DOCUMENTATION
X. DOCUMENTATION METHODS
XI. ASSESSMENT FORMS USED FOR DOCUMENTATION
XII. NURSING DISCHARGE/REFERRAL SUMMARIES
I. INTRODUCTION
The purpose of complete & accurate patient record
documentation is to foster quality & continuity of care.
Each health care organization has policies about
documentation & reporting client data, and each nurse is
accountable for practicing according to standards.
The ANA code of ethics (2001) states that “the nurse has a
duty to maintain confidentiality of all patient information.”
Documentation of 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 & guidelines of the
specific institutions mentioned previously & to develop a
plan of care for the client.
II. PURPOSES OF DOCUMENTATION
Documentation
▪ It is anything printed or written that can be used as a
record or proof for authorization.
▪ It serves as a comprehensive permanent record of client
information & care.
To promote effective communication among
multidisciplinary health team members to facilitate safe
& efficient client care. (Primary reason for
documentation of assessment data)
To provide the health care team with a database that
becomes the foundation for care of the client.
To identify health problems, formulate nursing
diagnoses, & plan immediate & ongoing interventions.
The use of electronic health records (EHRs) also increases
the likelihood that clients received life-saving treatments &
may lower the risk of hospital acquired infections.
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Validation & Documentation of Data
NCMA 111 - WEEK # 3 - LEC

Other Purposes of Documentation Write entries objectively without making premature

Communication judgments or diagnoses.
Plan of care-NCP Record client’s understanding and perception of problems.
Database health care analysis Avoid recording the word “normal” for normal findings.
For quality audits education and research legal purposes Record complete information and details for all client
symptoms or experiences.
III. PURPOSES OF ASSESSMENT DOCUMENTATION Include additional assessment content when applicable.
Support objective data with specific observations obtained
Provides a chronologic source of client assessment data and during the physical examination.
a progressive record of assessment findings that outline the
client’s course of care. VI. ASSESSMENT SPECIFIC DOCUMENTATION GUIDELINES
Ensures that information about the client and family is easily
accessible to members of the health care team; provides a Record pertinent positive and negative assessment data.
vehicle for communication; and prevents fragmentation, Document any parts of the assessment that are omitted or
repetition, and delays in carrying out the plan of care. refused by patient.
Establishes a basis for screening or validating proposed Avoid using judgmental language.
diagnoses. Avoid evaluative statements; cite specific statements or
Acts as a source of information to help diagnose new actions you observe.
problems. State time intervals precisely
Offers a basis for determining the educational needs of the Use specific measurements
client, family, and significant others. Draw pictures when appropriate
Provides a basis for determining eligibility for care and Refer to findings using anatomic landmarks
reimbursement. Careful recording of data can support Use the face of a clock to describe findings that are in a
financial reimbursement or gain additional reimbursement circular pattern
for transitional or skilled care needed by the client. Document any change in patient’s condition during a visit or
Constitutes a permanent legal record of the care that was or from previous visits
was not given to the client. Describe what you observed, not what you did.
Forms a component of client acuity system or client
classification systems (Eggland & Heinemann, 1994). Numeric VII. VAGUE VS. CLEAR & CONCISE DOCUMENTATION
values may be assigned to various levels of care to help
determine the staffing mix for the unit. Examples
Provides access to significant epidemiologic data for future Vague Documentation Clear & Concise Documentation
investigations and research and educational endeavors. Memory intact Recent & remote memory intact
Promotes compliance with legal, accreditation, Vital signs good Temperature: 37٥C; PR 66; RR 18;
reimbursement, and professional standard requirements. BP 120/80
Skin color normal Skin pink with consistent
IV. THINGS TO CONSIDER IN DOCUMENTATION pigmentation
Appetite good Reports no change in appetite
Legal record of patient encounter
Swelling of ankles Pitting edema 3+ of both ankles
May be used by many professionals
that lasts 10 seconds
Document in a professional & legally acceptable manner
Follow institution’s system Voids a lot Polyuria, urinary output = 3000
Ensure accuracy: mL/day
Ensure correct patient record or chart
Record information immediately upon completion of VIII. PATIENT’S RECORD
patient encounter
Avoid distractions while documenting The patient’s clinical record is also called the patient’s chart.
Date and time each entry It is a formal legal document that provides evidence of how
the patient’s care is managed.
V. GUIDELINES FOR DOCUMENTATION
IX. CHARTING OR DOCUMENTATION
Keep confidential all documented information in the client
record. Charting
Document eligibly or print neatly in non-erasable ink. ▪ It is the common term used in the field of nursing when
Use correct grammar and spelling. it comes to documentation.
Avoid wordiness that create redundancy.
Use phrases instead of sentences to record data.
Record data findings, not how they were obtained.

Transcriber: Lyanna Khalil Macayanan 2

Validation & Documentation of Data
NCMA 111 - WEEK # 3 - LEC
Nursing Documentation
▪ It is essential for good clinical communication that
provides an accurate reflection of nursing assessments,
patient changes in clinical state, care provided &
pertinent patient information to support the
multidisciplinary team to deliver great care.
Purposes of Charting
Serves as permanent record of patient’s information &
evidence of continuity of care.
Tracks progress of the patient’s condition during the
hospitalization as well as the status upon discharge.
Serves as an information sheet of the medications &
procedures rendered to the patient.
Legal evidence for cross-examination whenever
complaints or malpractice claims have been sighted out.
Serves as a research material for retrospective study.
Types of Charting
Narrative Charting
• The traditional form of charting.
• Source-oriented Record (SOR)
• Advantage - it provides organized section for each
member of the healthcare team.
• Disadvantage - the information is scattered
throughout the chart.
• Examples: treatment chart, admission sheet, initial
nursing assessment, and graphic record.
Problem-oriented Record (POR or POMR)
• Give focus on the problems that patients face
• Each medical personnel can contribute &
collaborate on the plan of care
• Advantage - collaboration among medical
personnel
• Disadvantage - takes complete & on time
assessment of problem lists
• Examples: Database, Problem List, Plan of Care,
Progress Notes
SOAP Formats (SOAPIE OR SOAPIER)
• This is 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 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 2 types of data. The nursing problem
is stated in a form of nursing diagnoses using
NANDA.
• P – Plan this includes the nursing actions to be made
to solve the stated problem. This part can be
revised.
• I – Intervention – part wherein specific nursing
actions are stated.
• E – Evaluation – part wherein the nurse evaluates
the reaction of the patient or progress of the
problem being solved.
• R - Revision – Section that states the changes made
to further resolve the problem.
• Example: SOAPIER
Case: A patient with hypersensitivity reaction
secondary to food intake.
S – “My skin is so itchy, especially on the skinfolds.”
O – Skin appears to be flushed with bumps.
Irritation noted on the armpit & inner thighs.
A – Altered comfort related to food intake.
P – Inform the patient not to scratch the skin. Apply
cold compress on the hot spots. Cut nails to prevent
skin scratches. Refer to the physician, Assess for
progress of skin rash.
I – Instructed not to scratch the skin. Cut the
fingernails short; Applied cold compress. Referred
to the physician.
E – “I feel more comfortable & I do not have the
urge to scratch my skin.”
R – Give antihistamine (Antamin) 1mg/mL as deep
IM (intramuscular injection) to left deltoid muscle as
per doctor’s order.
PIE – Problem Oriented Charting
• Like SOAP, PIE comes from the Nursing Process,
SOAP comes Medical Model.
• It consists of client care assessment flow sheet &
progress notes.
• Flow sheet uses specific assessment criteria.
• P – Problem
• I – Intervention
• E – Evaluation
Computerized Documentation
• Electronic Health Records (EHRs) are used to
manage huge volume of information required in
contemporary health care.
• It can integrate all pertinent client information into
one record.
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Validation & Documentation of Data
NCMA 111 - WEEK # 3 - LEC
X. DOCUMENTATION METHODS
Computerized Documentation
▪ Nurse’s responsibilities include storing client’s database,
add new data, create & revise care plans & document
client progress.
▪ Makes care planning & documentation relatively easy.
▪ Transmit information from one care setting to another.
Focus Charting (FDAR – Focus, Data, Action, Response)
▪ The client’s concerns & strengths are the focus of care.
▪ 3 columns for recording: Date & time, Focus, and
Progress Notes (DAR) - This type of charting involves
Data, Action & Response category.
• This is a client-focused charting wherein the client is
being talked about most of the documentation, this
is a form of holistic perspective of client’s needs.
▪ Example:
• F – (FOCUS) Nursing Dx, Client Concern, S&S, Event
• D – (DATA) Facial grimacing, graded the nape pain
as 7 scale out of 10.
• A – (ACTION) Given Norgesic Forte per orem as a
stat (now) dose as ordered by physician.
• R – (RESPONSE) Rated pain as 2 & able to walk on
her own.
SBAR (Situation, Background, Assessment,
Recommendation)
▪ It is a technique that can be used to facilitate prompt
and appropriate communication.
▪ SBAR is an evidence-based best practice communication
technique.
▪ A communication model that enhances efficient
communication that promotes effective collaboration,
improves patient outcomes, and increases patient
satisfaction with care.
▪ It is one of the most common handover mnemonic
models used in health care.
▪ It improves quality and patient safety outcomes when
used by health team members to communicate or hand-
off client information.
▪ S: Situation – state patient’s name, unit/ward, patient’s
problem
▪ B: Background – admission diagnosis, pertinent history,
current treatments
▪ A: Assessment – current VS, physical assessment, test
results
▪ R: Request/Recommendation – needs doctor’s
evaluation, further testing, transfer to higher level of
care
XI. ASSESSMENT FORMS USED FOR DOCUMENTATION
Initial Assessment Form
▪ It is called a nursing admission or admission database.
4 types
Open-ended forms (traditional form)
Cued or Checklist forms
Integrated Cued Checklist
Nursing Minimum Data Set
Frequent or Ongoing Assessment Form
▪ Flowcharts that help staff record and retrieve data for
frequent reassessments.
▪ Emphasis is placed on quality, not quantity of
documentation.
▪ Examples: Vital signs sheet, Assessment flowchart
Focused or Specialty Area Assessment Form
▪ Focused on one major area of the body for clients who
have a particular problem.
▪ Examples: Cardiovascular assessment forms, Neurologic
assessment forms
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 & Output Record
• Medication Administration Record (MAR)
• Skin Assessment Record
Transcriber: Lyanna Khalil Macayanan 4
Validation & Documentation of Data
NCMA 111 - WEEK # 3 - LEC

XII. NURSING DISCHARGE/REFERRAL SUMMARIES

Completed when the client is being discharged & transferred

to another institution or to a home setting where a visit by a
community health nurse is required REMEMBER!

Transcriber: Lyanna Khalil Macayanan 5