Ha Chapter 4

Front 1

Confirming or verifying subjective and objective data are accurate

Back 1

Validation of data

Front 2

Steps of validation

Back 2

Deciding whether the Data require validation

Determining ways to validate data

Identifying areas which data are missing

Hint 2

DDI

Front 3

Conditions that requires data to be rechecked

Back 3

Gaps between the subjective and objective data

Gaps between what the client says at one time versus another time

Findings that are highly abnormal and/or inconsistent with other findings

Hint 3

GGF

Front 4

Methods of validation

Back 4

Recheck data through repeat assessment

Clarify data with the client by asking questions

Verify data with another health care professional

Compare objective findings with subjective findings to uncover gaps

Hint 4

RCVC

Front 5

Another crucial part of the first step in nursing process

Back 5

Data analysis

Front 6

To promote effective communication among health team members

Provides the health care teams with a database that becomes the foundation for care of the client

Back 6

Documentation of assessment data

Front 7

Purposes of assessment documentation

Back 7

Establishes a basis for screening

Acts as a source of information to help diagnose new problems

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

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

Forms a component of client acuity system

Hint 7

FEACO

Front 8

Refered to medical records supplies by physicians who made medical diagnose and prescribed treatments

Back 8

EMR

Electronic medical record

Front 9

Refers to more comprehensive health status of the client and not only the medical status

Focuses on the total health (emotional, physical, social, spiritual) of the client

Back 9

Electronic health records EHR

Front 10

2 key elements in every documentation

Back 10

Nursing history

Physical assessment

(Also know as subjective and objective data)

Front 11

Subjective data consists of

Back 11

Biographic data

Present health concern and symptoms

Personal health history

Family history

Lifestyle and health practices information

Front 12

Consists of client's name, age, occupation etc.

Back 12

Biographic data

Front 13

Is recorded in statements that reflect th client's current symptoms

Back 13

Present health concern

Front 14

Events that happened before the client's admission to the health care facility

Back 14

Personal health history

Front 15

Includes information about the client's biological family

Genogram is helpful in recording family history

Back 15

Family history data

Front 16

Details about risk behaviors, such as poor nutrition, sun exposure, smoking , alcohol use, drug use, etc.

Back 16

Lifestyle and health practices information

Front 17

COLDSPA

Back 17

character

Onset

Location

Duration

Severity

Pattern

Associated factors

Front 18

Systematic approaches of objective data

Back 18

Head-to-toe

Major body systems

Human response patterns

Hint 18

HHM

Front 19

General rules of systematic approaches of objective data

Back 19

Make notes as you do the assessment and documents as concisely as possible

Avoid documenting with general non-descriptive or non measurable terms

Use specific, measurable terms about what you IPPA

Hint 19

MAU

Front 20

Guidelines for documentation

Back 20

Keep confidential all documented information in the client record

Document legibly

Use correct grammar and spelling

Avoid wordiness that create redundancy

Use phrases instead of sentences to record data

Record data finding, not how they were obtained

Write entries objectively without making premature judgements

Record the client's understanding and perception of the problem

Avoid recording the word "normal" in normal findings

Record complete information and details for all client symptoms

Include additional assessment content when applicable

Support objective data with specific observations obtained during physical examination

Hint 20

KAAWUURRRDIS

Front 21

3 types of assessment forms

Back 21

Initial assessment form

Frequent or ongoing assessment form

Focused or specialized assessment form

Front 22

Also Called a nursing admission or admission database

Back 22

Initial assessment form

Front 23

4 types of frequently used initial assessment forms

Back 23

open-ended

Cued or checklist

Integrated cued checklist

Nursing minimum data set

Front 24

Helps staff to record and retrieve data

Back 24

Frequent or ongoing assessment form

Front 25

Used to document unusual events, responses, significant observations or interactions

Back 25

Progress notes

Front 26

Focused on one major areas of the body for clients who have particular problem

Back 26

Focused or specialty area assessment form

Front 27

Required to verbally share their subjective and objective assessment findings

Back 27

Verbal communication of data

Front 28

Preventing communication data errors

Back 28

Use standardized method of data communication such as SBAR

Communicate face to face with good eye contact

Allow time for the receiver to ask questions

Provide documentation of data you are sharing

Validate what the receiver has heard by questioning

When reporting over the phone, ask the receiver to read back what he or she heard you report

Hint 28

PAVCUW

Front 29

Summary

Back 29

Validation, documentation and verbal communication of data are 3 crucial aspects of nursing health assessment