WEEK 6 - STEPS OF HEALTH ASSESSMENT
VALIDATING DATA
What is the purpose of validation?
Validation of data is the process of confirming or verifying that the subjective and objective
data you have collected are reliable and accurate. The steps of validation include:
deciding whether the data require validation,
determining ways to validate the data, and
identifying areas for which data are missing.
Failure to validate data may result in premature closure of the assessment or collection of
inaccurate data. Errors during assessment cause the health provider's judgments to be made on
unreliable data, which results in diagnostic errors during the second part of the health process—
analysis of data (collaborative problems, and referrals). Thus validation of the data collected
during assessment of the client is crucial to the first step of the health process.
When to validate data?
When there are discrepancies between the subjective and objective data, what the client
says at different times, or findings are abnormal and/or inconsistent.
Data Requiring Validation
Not every piece of data you collect must be verified. For example, you would not need to
verify or repeat the client's pulse, temperature, or blood pressure unless certain conditions exist.
Conditions that require data to be rechecked and validated include:
Discrepancies or gaps between the subjective and objective data. For example, a male
client tells you that he is very happy despite learning that he has terminal cancer.
Discrepancies or gaps between what the client says at one time versus another time. For
example, your female client says that she has never, had surgery, but later in the interview,
she mentions that her appendix was removed at a military hospital when she was in the
Navy.
Findings that are highly abnormal and/or inconsistent with other findings. For example,
the following are inconsistent with each other: the client has a temperature of 1040F, is
resting comfortably, and her skin is warm to the touch and not flushed.
Methods of Validation
There are several ways to validate your data:
Recheck your own data through a repeat assessment. For example, take the client's
temperature again with a different thermometer.
Clarify data with the client by asking additional questions. For example, if a client is
holding his abdomen, the health provider may assume that he is having abdominal pain,
when actually the client is very upset about his diagnosis and is feeling nauseated.
Verify the data with another health care professional. For example, ask a more
experienced the health provider to listen to the abnormal heart sounds you think you have
just heard.
Compare your objective findings with your subjective findings to uncover discrepancies.
For example, if the client states that she "never gets any time in the sun," yet has dark
wrinkled, suntanned skin, you need to validate the client's perception of never getting any
time in the sun by asking exactly how much time is spent working, sitting, or doing other
activities outdoors. Also, ask what the client wears when engaging in outdoor activities.
Steps of Validation
1) deciding whether the data require validation
2) determining ways to validate the data
3) identifying areas where data are missing
Ways to Validate Data
1) recheck your data via repeat assessment
2) clarify data with client by asking additional questions
3) verify data with another health care professional
4) compare objective findings with subjective findings to uncover discrepancies
DOCUMENTING DATA
In addition to validation, documentation of assessment data is another crucial part of the
first step in the health process. Health care institutions have developed assessment and
documentation policies and procedures that provide not only the criteria for documenting but also
assistance in completing the forms. The categories of information within the electronic health
record (EHR) are designed to ensure that the health provider gathers pertinent information
needed to meet the standards and guidelines of the specific institutions mentioned previously and
to develop a plan of care for the client.
Why documentation is important?
The primary reason for documentation of assessment data is to promote effective
communication among multidisciplinary health team members to facilitate safe and
efficient client care. Documented assessment data provide the health care team with a database
that becomes the foundation for care of the client. It helps identify health problems, and plan
immediate and ongoing interventions.
With the advent of computer-based documentation systems, these databases can link to
other documents and health care departments, eliminating repetition of similar data collection by
other health team members. The use of computer-based documentation systems has improved
diagnostic and clinical outcomes, reduced errors, and improved patient safety. Health providers
need to be involved in the selection of comprehensive and systematic care databases that
streamline data collection and organization and yet maintain a concise record that satisfies legal
standards
Purposes of Documentation
1. Provides a chronological source of client assessment data and a progressive record of assessment
findings that outline the client’s course of care.
2. Ensures that information about the client and family is easily accessible to members of the health
care team; provides a vehicle for communication; and prevents fragmentation, repetition, and
delays in carrying out the plan of care.
3. Establishes a basis for screening or validation proposed diagnoses.
4. Acts as a source of information to help diagnose new problems.
5. Offers a basis for determining the educational needs of the client, family, and significant others.
6. Provides a basis for determining eligibility for care and reimbursement. Careful recording of data
can support financial reimbursement or gain additional reimbursement for transitional or skilled
care needed by the client.
7. Constitutes a permanent legal record of the care that was or was not given to the client.
8. Provides access to significant epidemiologic data for future investigations and research and
educational endeavors.
Guidelines for Documentation
The way that health assessments are recorded varies among practice settings. However,
several general guidelines apply to all settings with both written notes and electronic
documentation methods. They include:
Keep confidential all documented information in the client record.
Document legibly or print neatly in nonerasable ink. Errors in documentation are usually
corrected by drawing one line through the entry, writing "error," and initialing the entry.
Use phrases instead of sentences to record data.
For example:
Avoid recording: "The client's lung sounds were clear both in the right and left lungs."
Instead record: "Bilateral lung sounds clear. "
Record data findings, not how they were obtained.
For example:
Do not record: "Client was interviewed for past history of high blood pressure, and blood
pressure was taken."
Instead record: "Has 3-year history of hypertension treated with medication. BP sitting
right arm 140/86, left arm 136/86."
Write entries objectively without making premature judgments. Use quotation marks to
identify clearly the client's responses.
For example:
Do not record: "Client depressed due to fear of breast biopsy report and not getting along
well with husband."
Record: "Client crying in room, refuses to talk, husband has gone home"
Record the client's understanding and perception of problems.
For example: "Client expresses concern regarding being discharged soon after gallbladder
surgery because of inability to rest at home with six children."
Record complete information and details for all client symptoms or experiences.
For example,
Do not record: "Client has pain in lower back."
Instead record: "Client reports aching-burning pain in lower back for 2 weeks. Pain worsens
after standing for several hours. Rest and ibuprofen used to take edge off pain. No radiation
of pain. Rates pain as 7 on scale of 1 to 10.
GENERALIZATION
Validation and Documentation are crucial aspect of health assessment. Health providers need to
concentrate on learning how to perform these skills steps of assessment thoroughly and accurately.
Validation of data verifies the assessment data that you have gathered from the client. Is consist of
determining which data require validation, implementing techniques to validate, and identify
areas that require further assessment data. Validating data: The information gathered during the
assessment phase must be complete, factual, and accurate because the interventions are based on
this information. Validation is the act of "double-checking" or verifying data to confirm that it is
accurate and factual.
Documentation of data is the act of recording the client assessment findings. Health providers
must first need to understand the purpose of documentation, next learn which information to
document, then be aware of and follow health care facility. In addition, it is important for you as
future health students to be familiar with the different ways of documenting. With documentation,
it provides a chronological source of client assessment data and a progressive record of assessment
findings that outline the client’s course of care. It also ensures that information about the client
and family is easily accessible to members of the health care team; provides a vehicle for
communication; and prevents fragmentation, repetition, and delays in carrying out the plan of
care.
“The ability to take data – to be able to
understand it, to process it, to extract value
from it, to visualize it, to communicate it – is
going to be a hugely important skill in the next
decades.”
Hal Varian
