Term
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Definition
| Process of confirming or verifying that the subjective data and objective data that you have collected is reliable and accurate (double-checking) |
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Term
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Definition
| Nursing diagnosis and interventions are determined from the data you collect during the assessment phase |
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Term
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Definition
*Ensure that the data collection is complete
*Ensure subjective and objective data agree
*Obtain additional data that may have been overlooked
*Avoid jumping to conclusions |
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Term
| Data Requiring Validation |
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Definition
*Not all data needs to be verified (Vital signs which are normal)
*Conditions that require validation would include:
*Discrepancies or gaps in subjective and objective data collected
*Discrepancies or gaps in what the client says one time to another
*Objective data that is inconsistent with other findings |
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Term
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Definition
*Repeat assessment (recheck patient's temperature with different thermometer)
*Clarify data (ask additional questions)
*Verify data with another healthcare professional (ask more experienced nurse to listen to abnormal heart sounds that you think you heard)
*Compare your objective findings with your subjective findings to uncover discrepancies |
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Term
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Definition
*Promote effective communication among multidisciplinary health team members to facilitate safe and efficient client care
*Helps to identify health problems, formulate nursing diagnosis, and plan immediate and ongoing interventions
*Acts as a source of information to help diagnose new problems
*Offers a basis for determining eligibility for care and reimbursement
*Constitutes a permanent legal record
*Forms a component of client acuity system to determine staffing ratios
*Provides access to epidemiologic data for future investigations and research
*Promotes compliance with legal, accreditation, reimbursement, and professional standard requirements |
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Term
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Definition
*Keep confidential all documented information in the client record (HIPPA)
*Document legibly or print neatly in non-erasable BLACK ink
*If you make an error:
-Draw one line through the entry, write "error" and initial
-NEVER use white-out or eraser
*Use correct grammar
*Legal document
*Document legible or print
*Use only abbreviations that are acceptable and approved by the institution
*Avoid wordiness- not a novel, creates redundancy
*Use phrases instead of sentences |
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Term
| Assessment Forms for Documentation |
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Definition
*Initial Assessment form: nursing admission or admission database (comprehensive interview)
*Frequent or Ongoing Assessment Form: Flow charts (flowsheets) that staff use to record and retrieve data for frequent assessments
*Focused or Specialty Area Assessment Form: Focus on one major area of the body for clients who have a particular problem (cardiovascular, neuro) |
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Term
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Definition
*Ongoing Assessment
*Used to document unusual events or responses
*Emphasis placed on quality not quantity of documentation |
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Term
| Verbal Communication of Data |
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Definition
*Use standardized method of data communication such as SBAR
*Communicate face to face w/ good eye contact
*Allow time for the receiver to ask questions
*Provide documentation of the data you are sharing
*Validating what the receiver has heard by questioning or asking the receiver to summarize your report
*When reporting over the telephone, ask the receiver to read back what the receiver heard you report and document the phone call time, receiver, sender, and information shared |
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Term
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Definition
*Situation
*Background
*Assessment
*Recommendation |
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Term
| Face to Face Verbal Report |
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Definition
*Good eye contact
*Allow time for the receiver to ask questions
*Provide documentation of data you sharing
*Validate what the receiver had heard by questioning or asking him/her to summarize your report |
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Term
| Giving Report Over the Phone |
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Definition
*Ask the receiver to read back what he/she heard you report
*Document phone call with time, sender, the information shared |
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Term
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Definition
*Situation
*"I am calling about [Patient's name]"
* Code status
*"The problem I'm calling about is ________"
*I have just assessed the patient personally
-Vital signs are: (BP, Pulse, Respiration, and Temperature)
*"I am concerned about the ______" |
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Term
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Definition
*Background
*The patients mental status
*The skin Is
*The patient is/is not on oxygen |
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Term
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Definition
*Assessment
*This is what I think the problem is: say what you think is the problem
*The problem seems to be cardiac infection neurologic respiratory _____
*I am not sure what the problem is but the patient is deteriorating.
*The patient seems to be unstable and may get worse, we need to do something. |
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Term
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Definition
*Recommendation
*"I suggest or request that you ______"
*Are any tests needed
-Do you need any tests like CXR, ABG, EKG, CBC, or BMP? Others?
*If a change in treatment is ordered, then ask:
-How often do you want vital signs?
-How long to you expect this problem will last?
-If the patient does not get better when would you want us to call again? |
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