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8 III. STEPS OF HEALTH ASSESSMENT - C & D Validation and Documentation

This document outlines the steps of health assessment, including collecting subjective and objective data, validating the data, and documenting the data. It discusses collecting biographical, physical, and lifestyle information from clients through questions and direct observation. It emphasizes validating data by checking for discrepancies and clarifying unclear information. Finally, it explains the importance of thorough and accurate documentation to provide a record of client assessments and information for health professionals.

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Shaniee G.
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934 views18 pages

8 III. STEPS OF HEALTH ASSESSMENT - C & D Validation and Documentation

This document outlines the steps of health assessment, including collecting subjective and objective data, validating the data, and documenting the data. It discusses collecting biographical, physical, and lifestyle information from clients through questions and direct observation. It emphasizes validating data by checking for discrepancies and clarifying unclear information. Finally, it explains the importance of thorough and accurate documentation to provide a record of client assessments and information for health professionals.

Uploaded by

Shaniee G.
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PDF, TXT or read online on Scribd
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Steps of Health Assessment

Part 2
STEPS OF HEALTH ASSESSMENT

• Collection of subjective data


• Collection of objective data
• Validation of data
• Documentation of data
1.Collection of subjective data
• Sensations or symptoms • Beliefs
• Feelings • Ideas
• Perceptions • Values
• Desires • Personal information
• Preferences
Major areas of subjective data
• Biographical information
• Physical symptoms related to body parts
• Past health history
• Family history
• Health and lifestyle practices
2.Collection of objective data
Directly observed by the examiner
Include:
• Physical characteristics
• Body functions
• Appearance
• Behavior
• Measurements
• Results of laboratory testing
3. Validating assessment data
• Ensure all relevant data have been collected
• Prevent documentation of inaccurate data
Validating data

• Process of confirming or verifying that the subjective and


objective data you have collected are reliable and accurate
Steps of validation
• Deciding whether data requires validation
• Determining ways to validate data
• Identifying areas where data are missing
Data requiring validation
• Discrepancies or gaps between the subjective and objective data
• Discrepancies or gaps between what the client say at one time then
at another time
• Findings that are very abnormal or inconsistent with other findings
Methods of validation

• Recheck your own data


• Clarify data by asking additional questions
• Verify data with another health care professional
• Compare your objective findings with your subjective findings to uncover
discrepancies
4. Documenting data
Purposes of documentation
• Primary reason is to provide data base
• Provides source of client assessment data
• Ensures information about the client and family is easily accessible among
health team members
• Helps identify health problems and formulate nursing diagnosis and
information
• Determines educational needs of clients, family and significant others
Purposes of documentation

• Provides basis for eligibility to reimbursements


• Constitutes a permanent legal record
• May be used for future investigations and research
TYPES OF documentation

❑Written Notes
❑Electronic Documentation
GUIDELINES FOR DOCUMENTATION

• Ensure that you have the correct client record or chart and that the client’s
name and identifying information are on every page of the record
• Document as soon as the client encounter is concluded to ensure accurate
recall of data
• Date and time each entry
• Sign each entry with your full legal and with your professional credentials
• Do not leave space between entries
• If an error is made, use a single line to cross out the error, then date, time
and sign the correction
• Never change another person’s entry, even if it is incorrect
• Use quotation marks to indicate client responses
• Document in chronological order
• Write legibly
• Use a permanent-ink pen
• Document in a complete but concise manner by using phrases and
abbreviations
• Document all telephone calls that you make or receive related to a client’s
case

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