Chapter 4 Validating and Documenting Data
Learning Objectives
1. Describe the significance and process for validation of client data.
a. Validation: verification that subjective & objective data are reliable &
accurate.
b. Failure to validate:
i. Result in premature closure of assessment
ii. Collection of innacurate data
iii. Nurse’s judgement is made on unreliable data, which causes
diagnostic errors.
c. process:
i. Deciding whether the data requires validation
ii. Determining ways to validate the data
iii. Identify areas where data is missing.
2. Discuss situations that require client data to be rechecked or verified.
a. Discrepancies/ gaps btw subj. & obj. data
i. Ex: a pt tells you they are happy despite learning that he has
terminal cancer
b. Discrepancies/ gaps btw what the client says one time v. the other.
i. Ex: pt says they’ve never had surgery but later says they
removed her appendix
c. Findings are abnormal/ inconsistent w/ other findings
i. Ex: pt has a temp of 104 F & is resting comfortably, & sking is
warm to touched & not flushed.
d. NOT ALL data needs to be validated
i. Ex: verifying vital signs if within normal range.
e. Methods of validation:
i. Repeat assessment
ii. Clarify w/ the client by asking additional questions
iii. Verify the data w/ another HCT member
iv. Compare obj. findings w/ subj. findings
3. Describe the multiple purposes of accurate and timely documentation of client
data.
a. Documentation provides a chronological source of client assessment
data & a progressive record of assessment findings that outline the
client’s course of care.
b. Purposes:
i. Promote effective communication among the HCT to facilitate
safe & efficient care.
ii. It becomes the foundation for care of the client.
iii. Ensures that info about the pt is easily accessible.
iv. Provides a basis for determining eligibility for care &
reimbursement.
v. Permanent legal record
vi. Resource for communication
vii. Prevents fragmentation, repetition, & delays when caring for a
pt.
, 4. Identify safe guidelines for documentation of client data.
a. Keep confidential all documented info (HIPAA)
b. Document legibly/ print neatly w/ nonerasable ink.
i. Correct errors by drawing one line through the entry, writing
“Error”, & initialing the entry
c. Use correct grammar & spelling
d. Avoid wordiness that creates redundancy
e. Uses phrases rather than complete sentence
f. Record data findings, not how they were obtained
g. Write entries objectively w/o making premature judgments.
h. Record client’s understanding & perception of problems
i. Avoid recording the word “normal” for normal findings
j. Record comple infor & details for all client symptoms.
k. Include additional assessment content when applicable.
l. Support obj. dat w/ specific observations obtained during physical
exam.
TABLE 4-1 Examples of Vague Versus Clear and Concise
Documentation of Data
Vague Documentation Clear and Concise Documentation
Source and reliability of Client awake, alert, and oriented to person, place, time, and events. Initiates
information: Client and maintains conversation. Asks and answers questions that are
appropriate.
Memory intact Recent and remote memory intact.
Vital signs good Temperature: 98.6 degrees F; Pulse 66 regular Respirations 18, Blood pressure:
160/88
Skin color normal Skin pink with consistent pigmentation
Appetite good Reports no change in appetite (list 24-hour diet recall on a typical day)
Swelling of ankles Pitting edema 3+ of both ankles that lasts 10 seconds
Hears poorly “My wife says I always turn the radio and TV up too loud so I guess I am hard of
hearing”
Heart rate regular Heart regular rate and rhythm: S1 and S2 present; S1 loudest at the apex, S2
Learning Objectives
1. Describe the significance and process for validation of client data.
a. Validation: verification that subjective & objective data are reliable &
accurate.
b. Failure to validate:
i. Result in premature closure of assessment
ii. Collection of innacurate data
iii. Nurse’s judgement is made on unreliable data, which causes
diagnostic errors.
c. process:
i. Deciding whether the data requires validation
ii. Determining ways to validate the data
iii. Identify areas where data is missing.
2. Discuss situations that require client data to be rechecked or verified.
a. Discrepancies/ gaps btw subj. & obj. data
i. Ex: a pt tells you they are happy despite learning that he has
terminal cancer
b. Discrepancies/ gaps btw what the client says one time v. the other.
i. Ex: pt says they’ve never had surgery but later says they
removed her appendix
c. Findings are abnormal/ inconsistent w/ other findings
i. Ex: pt has a temp of 104 F & is resting comfortably, & sking is
warm to touched & not flushed.
d. NOT ALL data needs to be validated
i. Ex: verifying vital signs if within normal range.
e. Methods of validation:
i. Repeat assessment
ii. Clarify w/ the client by asking additional questions
iii. Verify the data w/ another HCT member
iv. Compare obj. findings w/ subj. findings
3. Describe the multiple purposes of accurate and timely documentation of client
data.
a. Documentation provides a chronological source of client assessment
data & a progressive record of assessment findings that outline the
client’s course of care.
b. Purposes:
i. Promote effective communication among the HCT to facilitate
safe & efficient care.
ii. It becomes the foundation for care of the client.
iii. Ensures that info about the pt is easily accessible.
iv. Provides a basis for determining eligibility for care &
reimbursement.
v. Permanent legal record
vi. Resource for communication
vii. Prevents fragmentation, repetition, & delays when caring for a
pt.
, 4. Identify safe guidelines for documentation of client data.
a. Keep confidential all documented info (HIPAA)
b. Document legibly/ print neatly w/ nonerasable ink.
i. Correct errors by drawing one line through the entry, writing
“Error”, & initialing the entry
c. Use correct grammar & spelling
d. Avoid wordiness that creates redundancy
e. Uses phrases rather than complete sentence
f. Record data findings, not how they were obtained
g. Write entries objectively w/o making premature judgments.
h. Record client’s understanding & perception of problems
i. Avoid recording the word “normal” for normal findings
j. Record comple infor & details for all client symptoms.
k. Include additional assessment content when applicable.
l. Support obj. dat w/ specific observations obtained during physical
exam.
TABLE 4-1 Examples of Vague Versus Clear and Concise
Documentation of Data
Vague Documentation Clear and Concise Documentation
Source and reliability of Client awake, alert, and oriented to person, place, time, and events. Initiates
information: Client and maintains conversation. Asks and answers questions that are
appropriate.
Memory intact Recent and remote memory intact.
Vital signs good Temperature: 98.6 degrees F; Pulse 66 regular Respirations 18, Blood pressure:
160/88
Skin color normal Skin pink with consistent pigmentation
Appetite good Reports no change in appetite (list 24-hour diet recall on a typical day)
Swelling of ankles Pitting edema 3+ of both ankles that lasts 10 seconds
Hears poorly “My wife says I always turn the radio and TV up too loud so I guess I am hard of
hearing”
Heart rate regular Heart regular rate and rhythm: S1 and S2 present; S1 loudest at the apex, S2
