Chapter 4 + 5 - CHAPTERS 4 5 Chapter 4 Validating and Documenting Data VALIDATING DATA Conditions that require data to be rechecked and validated

Chapter 4 + 5 - CHAPTERS 4 5 Chapter 4 Validating and...

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CHAPTERS 4 & 5 Chapter 4 - Validating and Documenting Data VALIDATING DATA Conditions that require data to be rechecked and validated include: - Discrepancies/gaps between subjective and objective data (client is happy despite learning he has cancer - Discrepancies or gaps between what the client says at one time and mentions another time (saying they never had surgery but mentions having appendix removed last yr) - Finding something abnormal that doesn’t match other expected symptoms such a 104F temp and pt is calm not flushed. Methods of validation: - Repeat assessment - Clarify data with client - Verify with another clinician - Compare objective findings with subjective findings to find discrepancies Identification of areas of missing data: - If adult pt weighs 98 lbs, you would explore if they recently lost weight or is this a usual weight DOCUMENTING DATA Main purpose: promote effective communication among multidisciplinary health team members to facilitate safe and efficient client care. Guidelines for documentation: - Keep confidential - Document legibly - Correct grammar and spelling - Avoid wordiness/redundancy - Use phrases NOT sentences -
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