VALIDATING ASSESSMENT DATA

Validation of assessment data is a crucial part of the assessment that often occurs along
with subjective and objective data collection. It ensures that the assessment process is
not ended before all relevant data have been collected and helps prevent
documentation of inaccurate data. What types of assessment data should be validated,
the different ways to validate data, and identifying areas where data are missing are all
parts of the process.

METHODS OF VALIDATION

There are several ways to validate your data:

● Recheck your data through a repeat assessment. For example, retake the client’s
temperature with a different thermometer.

● Clarify data with the client by asking additional questions. For example, suppose a
client is holding his abdomen. In that case, the nurse may assume he is having
abdominal pain when the client is very upset about his diagnosis and feels nauseated.

● Verify the data with another health care professional. For example, ask a more
experienced nurse to listen to the abnormal heart sounds you think you have just heard.

● Compare your objective findings with your subjective findings to uncover

discrepancies. For example, if the client states that she “never gets any time in the sun,”
yet has dark, wrinkled, suntanned skin, you need to validate the client’s perception of
never getting any time in the sun by asking exactly how much time is spent working,
sitting, or doing other activities outdoors. Also, ask what the client wears when engaging
in outdoor activities.

DOCUMENTING DATA

Documentation of assessment data is an essential step of assessment because it forms

the database for the entire nursing process and provides data for all other members of
the health care team. Thorough and accurate documentation is vital to ensure that valid
conclusions are made when the data are analyzed in the second step of the nursing
process.

GUIDELINES FOR DOCUMENTATION

The way that nursing assessments are recorded varies among practice settings.
However, several general guidelines apply to all settings with written notes and
electronic documentation methods. They include:

● Keep confidential all documented information in the client record. Most agencies
require nurses to complete the health training to ensure that the use, disclosure of, and
requests for protected data is used only for intended purposes and kept to a minimum.
Clients must also be educated on their rights.

● Document legibly or print neatly in non-erasable ink. Errors in the documentation

are usually corrected by drawing one line through the entry, writing “error,” and
initialing the entry. Never obliterate the error with white paint or tape, an eraser, or a
marking pen. Keep in mind that the health record is a legal document.

● Use correct grammar and spelling. Use only abbreviations that are acceptable
and approved by the institution. Avoid slang, jargon, or labels unless they are direct
quotes.

● Avoid wordiness that creates redundancy. For example, do not record:

“Auscultated gurgly bowel sounds in right upper, right lower, left upper, and left lower
abdominal quadrants. Head 36 gurgles per minute.’’ Instead, record ‘’Bowel sounds
present in all quadrants at 36/per minute’’.

● Use phrases instead of sentences to record data. For example, avoid recording:
“The client’s lung sounds were clear both in the right and left lungs.” Instead, record:
“Bilateral lung sounds clear.”

● Record data findings, not how they were obtained. For example, do not record:
“Client was interviewed for the history of high blood pressure, and blood pressure was
taken.” Instead, record: ‘’ Has a 3-year history of hypertension treated with medication.
BP sitting right arm140/86, left arm 136/86.’’

● Write entries objectively without making premature judgments or diagnoses. Use

quotation marks to identify the client’s responses. For example, record: “Client crying in
the room, refuses to talk, the husband has gone home” instead of “Client depressed due
to fear of breast biopsy report and not getting along well with husband.” Avoid making
inferences and diagnostic statements until you have collected and validated all data with
the client and family.
● Record the client’s understanding and perception of problems. For example,
record: “Client expresses concern regarding being discharged soon after gallbladder
surgery because of inability to rest at home with six children.”