NCM 101 Health Assessment
Chapter 4: Validating and Documenting Data I
4.1 Define related terms
Validation of data - process of confirming or verifying that the subjective and
objective data you have collected are reliable and accurate
Documentation of data - provide the health care team with a database that becomes
the foundation for care of the client
4.2 Discuss the purpose of validation and documentation
Purpose of validation
- Identify areas for which data are missing
- Failure to validate data may result in the collection of inaccurate data
Purpose of documentation
- Provide a legal record of a client’s care
4.3 Identify conditions that require data to be rechecked and validated
Data requiring validation
- Discrepancies or gaps between the subjective and objective data
- Discrepancies or gaps between what the client says at one time vs. another time
- Findings that are highly abnormal and/or inconsistent with other findings
4.4 List down the methods of validation
- 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
4.5 Enumerate information requiring documentation
Subjective data
- Biographical data
- Present health concerns and symptoms
- Personal health history
- Family history
- Lifestyle and health practices information
Objective data - conduct of physical examination that includes IPPA
General rules in documenting objective data
- Make notes as you perform the assessments and document as concisely as
possible
- Avoid documenting with general non-descriptive or non-measurable terms
- Instead use specific descriptive and measurable terms
4.6 State the guidelines for documentation
- Keep confidential all documented information in the client record
- Document legibly or print neatly in non-erasable ink
- Use correct grammar and spelling
- Avoid wordiness that creates redundancy
- Use phrases instead of sentences to record data
- Record data findings, not how they were obtained
- Write entries objectively without making premature judgments or diagnoses
- Record the client’s understanding and perception of problems
Chapter 4: Validating and Documenting Data I
4.1 Define related terms
Validation of data - process of confirming or verifying that the subjective and
objective data you have collected are reliable and accurate
Documentation of data - provide the health care team with a database that becomes
the foundation for care of the client
4.2 Discuss the purpose of validation and documentation
Purpose of validation
- Identify areas for which data are missing
- Failure to validate data may result in the collection of inaccurate data
Purpose of documentation
- Provide a legal record of a client’s care
4.3 Identify conditions that require data to be rechecked and validated
Data requiring validation
- Discrepancies or gaps between the subjective and objective data
- Discrepancies or gaps between what the client says at one time vs. another time
- Findings that are highly abnormal and/or inconsistent with other findings
4.4 List down the methods of validation
- 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
4.5 Enumerate information requiring documentation
Subjective data
- Biographical data
- Present health concerns and symptoms
- Personal health history
- Family history
- Lifestyle and health practices information
Objective data - conduct of physical examination that includes IPPA
General rules in documenting objective data
- Make notes as you perform the assessments and document as concisely as
possible
- Avoid documenting with general non-descriptive or non-measurable terms
- Instead use specific descriptive and measurable terms
4.6 State the guidelines for documentation
- Keep confidential all documented information in the client record
- Document legibly or print neatly in non-erasable ink
- Use correct grammar and spelling
- Avoid wordiness that creates redundancy
- Use phrases instead of sentences to record data
- Record data findings, not how they were obtained
- Write entries objectively without making premature judgments or diagnoses
- Record the client’s understanding and perception of problems
