CHAP 4 Flashcards
the process of confirming or verifying that the subjective and objective data you have collected are reliable and accurate
Validation of data
Conditions that require data to be rechecked and validated
include the following:
- Discrepancies or gaps between the subjective and objective data
- Discrepancies or gaps between what the client says at one time versus another
time - Findings that are highly abnormal and/or inconsistent with other findings
ways to validate data
Recheck your own data through a repeat assessment
Clarify data 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.
2 types of documentation
Vague
clear and concise
three types of assessment forms
are used to document data:
Initial
Frequent/ongoing
Focused
is called a “nursing admission or admission database.”
Initial
this documentation consist of openended, cued or checklist, integrated cued checklist, and nursing minimum data set
(NMDS) forms.
Initial
cardiovascular or neurologic assessment documentation forms is under what type f assesment form
focused
model of communication is used throughout this book to
demonstrate a consistent way to communicate assessment data
SBAR
Meaning of SBAR
Situation
Background
Assessment
Recommendation