VALIDATING &

DOCUMENTING DATA
DIANA ROSE D. EMERENCIANA,RN.MAN
PURPOSE OF VALIDATION
 Confirm & verify that the subjective & objective
data collected are reliable & accurate
STEPS OF VALIDATION

VALIDATION IDENTIFY
WAYS TO
REQUIREMEN MISSING
VALIDATE
T DATA
DATA REQUIRING VALIDATION
• Discrepancies or gaps b/w subjective & objective
1. data

• Discrepancies or gaps b/w what the client says at

2. one time versus another time

• Findings that are highly abnormal and/ or

3. inconsistent with each other
 METHODS OF VALIDATION

 Recheck data through repeat assessment

 Clarify data with the client
 Verify the data with another health professional
 Compare objective findings with subjective findings
to uncover discrepancies
IDENTIFICATION OF MISSING DATA

 Establish an initial database to identify areas for

which more data are needed
 look for overlooked question
 examine data in a group format
 DOCUMENTING DATA

 Health care institutions have their own policies/ procedure

in documentation that provide not only the criteria for
documenting but also assistance in completing the forms

 Electronic Health Record (EHR) are designed to ensure

that the nurse gathers pertinent information needed to meet
the standards & guidelines of the specific institutions and
to develop a plan of care for the client
 DOCUMENTATION
 Promote effective communication among health team to
facilitate safe & efficient client care
 documented assessment data provide database that
becomes the foundation for care of the client
 Helps identify health problems, formulate nursing
diagnoses and plan immediate & ongoing interventions
 PURPOSES OF DOCUMENTATION
 Provides a chronological source of client assessment data & a
progressive record of assessment findings that outline the
client’s course of care
 Ensures that information about the client and the family is
easily accessible to members of the health care team
 Establishes a basis for screening or validating proposed
diagnoses
 Acts as source of information to help diagnose new problems
 PURPOSES OF DOCUMENTATION
 offers a basis for determining the educational needs of the
client, family and SO
 provides a basis for determining eligibility for care and
reimbursement
 constitute a permanent legal record of the care that was or was
not given to the client
 forms a component for client acuity system or client
classification system
 Provides access to significant epidemiologic data for
investigation
 Promote compliance with legal, accreditation, reimbursement
and professional standard requirements
Information Requiring Documentation

NURSING HISTORY (SUBJECTIVE)

PHYSICAL ASSESSMENT
(OBJECTIVE)
“ It is important to remember to document only what
the client tells you and
what you observe
not what you interpret or
infer from the data”
DOCUMENTATION OF SUBJECTIVE
DATA
 document data as describe and stated by the client
 do not interpret
DOCUMENTATION OF OBJECTIVE DATA

Make notes while performing the assessment; document

concisely

Avoid documenting with general non-descriptive or non-

measurable terms

Use specific descriptive and measurable terms

 GUIDELINES FOR THE
DOCUMENTATION
 Keep documents confidential
 Document legibly or print neatly in nonerasable ink
 Use correct grammar or spelling. Use only acceptable
abbreviations
 Avoid redundancy
 Use phrases instead of sentences to record data
 Record data findings not how they were obtained
 Write entries objectively without making premature
judgement or diagnoses
 GUIDELINES FOR THE
DOCUMENTATION
 Record the client’s understanding & perception of problems
 Avoid recording the word normal for normal findings
 Record complete information & details of client’s symptoms/
experiences
 Include additional assessment content when applicable
 Support objective data with specific observations obtained
during the PE
Thank You!!!