DOCUMENTING DATA

 Another crucial part of the first step in the nursing process

 Addressed specifically by various state nurse practice acts, accreditation

and/or reimbursement agencies, professional organizations, professional
organizations

 Categories of information on the forms are designed to ensure that the nurse
gathers pertinent information needed to meet the standards and guidelines of
the specific institutions and to develop a plan of care for the client.

PURPOSE OF DOCUMENTATION

 Provides a chronologic source of client assessment data and a progressive

record of assessment findings that outline the client’s course of care

 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

 Establishes a basis for screening or validating proposed diagnoses

 Acts as a source of information to help diagnose new problems

 Offers a basis for determining the educational needs of the client, family, and
significant others

 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

 Constitutes a permanent legal record of the care that was or was not given to
the client.

 Forms a component of client acuity system or client classification systems

(Eggland & Heinemann, 1994)

 Numeric values may be assigned to various levels of care to help determine

the staffing mix for the unit
  Provides access to significant epidemiologic data for future investigations
and research and educational endeavors.

 Promotes compliance with legal, accreditation, reimbursement, and

professional standard requirements.

INFORMATION REQUIRING DOCUMENTATION

Subjective Data

 Typically consist of biographic data, current health concern(s) and

symptoms (or the client’s chief complaint), past health history, family
history, and lifestyle and health practices information

 Includes:

 client’s name, age, occupation, ethnicity, and support systems or

resources

 present health concern review is recorded in statements that

reflect the client’s current symptoms

 describe items as accurately and descriptively as possible

 use a memory tool to further explore every symptom reported

by the client

 past health history data tell the nurse about events that happened
before the client’s admission to the health care facility or the
current encounter with the client

 family history data include information about the client’s

biologic family

 lifestyle and health practices information typically details risk

behaviors

 be sure to be comprehensive, yet succinct

 Objective Data

 Includes inspection, palpation, percussion, and auscultation

 Help to further define the client’s problems, establish baseline data for
ongoing assessments, and validate the subjective data obtained during
the nursing history interview

 General rules apply:

 make notes as you perform the assessments, and document as

concisely as possible

 avoid documenting general non-descriptive or nonmeasurable

terms such as normal, abnormal, good, fair, satisfactory, or poor

 instead, use specific descriptive and measurable terms about

what you inspected, palpated, percussed, and auscultated

GUIDELINES FOR DOCUMENTATION

 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.

 Avoid recording the word “normal” for normal findings.

 Record complete information and details for all client symptoms or

experiences.

 Include additional assessment content when applicable.

  Support objective data with specific observations obtained during the
physical examination.

ASSESSMENT FORMS USED FOR DATA

Initial Assessment Form

 Called a nursing admission or admission database

 Has four (4) different types:

1. Open-Ended Forms (Traditional Form)

 Calls for narrative description of problem and listing of topics

 Provides lines for comments

 Individualizes information

 Provides “total picture,” including specific complaints and

symptoms in the client’s own words

 Increases risk of failing to ask a pertinent question because questions

are not standardized

 Requires a lot of time to complete the database

2. Cued or Checklist Forms

 Standardizes data collection

 Lists (categorizes) information that alerts the nurse to specific

problems or symptoms assessed for each client

 Usually includes a comment section after each category to allow for

individualization

 Prevents missed questions

 Promotes easy, rapid documentation

 Makes documentation somewhat like data entry because it requires

nurse to place checkmarks in boxes instead of writing narrative
  Poses chance that a significant piece of data may be missed because
the checklist does not include the area of concern

3. Integrated Cued Checklist

 Combines assessment data with identified nursing diagnoses

 Helps cluster data, focuses on nursing diagnoses, assists in

validating nursing diagnosis labels, and combines assessment with
problem listing in one form

 Promotes use by different levels of caregivers, resulting in enhanced

communication among the disciplines

4. Nursing Minimum Data Set

 Comprises format commonly used in long-term care facilities

 Has a cued format that prompts nurse for specific criteria; usually
computerized

 Includes specialized information, such as cognitive patterns,

communication (hearing and vision) patterns, physical function and
structural patterns, activity patterns, restorative care, and the like

 Meets the needs of multiple data users in the health care system

 Establishes comparability of nursing data across clinical populations,

settings, geographic areas, and time

Frequent or Ongoing Assessment Form

 Flow charts that help staff to record and retrieve data for frequent
reassessments

 Frequent Vital Signs Sheet - allows for vital signs to be recorded in a graphic
format that promotes easy visualization of abnormalities

 Assessment Flow Chart - allows for rapid comparison of recorded assessment

data from one time period to the next
  Progress Notes - may be used to document unusual events, responses,
significant observations, or interactions because the data are inappropriate for
flow records

 Flow Sheets - streamline the documentation process and prevent needless

repetition of data

Focused or Specialty Area Assessment Form

 Forms that are focused on one major area of the body for clients who have a
particular problem

 Usually abbreviated versions of admission data sheets with specific

assessment data related to the purpose of the assessment

REFERENCES:

Kelley, J., Sprengel, A., Weber, J.. Health Assessment In Nursing Fourth Edition
(2009). Lippincott. Williams and Wilkins. Wolters Kluwer.