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.
