Whenever data are gathered from support people, this
should be indicated in the health history. When the person
does not speak English, the services of an interpreter are
needed. It is important not to assume that a family member
is accurately translating what you are trying to communicate
to the person. It is now policy in many health services that
family members are not used as interpreters since family
members might misinterpret medical content or paraphrase
the person’s response incorrectly, or the person might be
uncomfortable sharing certain information with the family
interpreter. For example, in some cultures it is inappropriate
to discuss certain issues with one gender, and using a family
member may cause embarrassment to both parties. When
using family and friends as a source of information, you can
add to the knowledge and understanding of the person and
this can assist with validating the problems identified.
Patient record
Records prepared by different members of the healthcare
team provide information essential to the delivery of com-
prehensive care. You should review records early when
gathering data—in some instances, before the first contact
with the person. Such a review helps to focus the health
assessment and to confirm and amplify information obtained
from other sources.
The patient health record or chart, which lists demo-
graphic information such as age, gender, occupation,
religious preference and next of kin, is one type of record.
The patient record includes information entered by various
health professionals, such as doctors, social workers, dieti-
cians, physiotherapists and laboratory technicians.
You must be familiar with the many sections of the patient
record, in addition to the documentation of the plan of care
and notes. The following are important sources of data.
Medical history, physical examination and progress notes
Medical history, physical examination and progress notes
record the findings of doctors as they assess and treat the
person; they focus on identifying pathological conditions
and their causes and on determining the medical regimen for
treatment.
Consultations
The person’s doctor may invite specialists to assess and to
work with the person. Their focus is on identifying findings
that help to establish a medical diagnosis or on planning and
executing the treatment regimen.
Reports of laboratory and other diagnostic studies
Reports of laboratory studies and other diagnostic tests, such
as X-rays, offer objective data that can either confirm or
conflict with data collected during the health history or
examination. Results of diagnostic studies are helpful to
doctors for establishing a diagnosis and monitoring the
person’s response to treatment. The results of these same
studies may also be helpful in evaluation of care and the
success of your care interventions.
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Chapter 15 Assessing
Reports of therapies by other health professionals
Other healthcare professionals who interact with the person
also record their findings and note any progress that the
person is making in their specific areas—for example,
nutrition, physiotherapy or speech therapy. These reports
help you assess the person’s progress and are useful when
determining their ability to return home and manage care
independently.
Records of previous admissions for healthcare and
records from other health agencies, such as a social service
agency or community agency, are also valuable sources of
data. They contain information about the person’s previ-
ous medical or surgical problems and response patterns,
which may be important determinants of the current plan
of care.
Other health professionals
You can learn a great deal about a person’s normal health
habits and patterns and their response to illness by talking
with colleagues, doctors, social workers and others in the
healthcare team. Although such communication is always
important, it can be crucial when a person is transferred
from home to a hospital or from one hospital to another. The
only way to ensure continuity of care is to make special
efforts to share pertinent information.
Nursing and midwifery and other
healthcare literature
To obtain a comprehensive personal database, it may be nec-
essary to consult the nursing, midwifery and related literature
on specific health problems. For example, if you have not
cared for a person with Paget’s disease before, it is important
for you to read about the clinical manifestations of the
disease and its usual progression to know what to look for
during the assessment. In addition to information concerning
medical diagnoses, treatment and prognosis, literature
review offers you important information about problems,
developmental norms and psychosocial and spiritual prac-
tices, which is helpful when assessing and providing care.
Components of data collection
Components of data collection include the health history
and physical assessment. These data may be documented on
a separate assessment tool or incorporated into a combined
database assessment form.
Observation
Observation
is a fundamental skill that all nurses and mid-
wives require and will use in many key aspects of practice.
This includes gathering the health history or performing the
physical examination. Observation is the conscious and
deliberate use of the five senses to gather data. Skilled
nurses and midwives use each interaction with the person to
observe and to interpret meaningful data. This process
begins from the first encounter with the person and family.
