Documentation
The initial database should be entered into the computer or
recorded in ink, using the designated healthcare facility forms,
on the same day the person is admitted. If, for any reason,
important data cannot be obtained during the initial assess-
ment, this needs to be documented so that they are obtained
as soon as possible. Objective and subjective personal
data should be summarised and written in a comprehensive,
Unit III Thoughtful practice and the process of care
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concise and easily retrievable format. The data should be
written legibly, using good grammar, and only the abbrevia-
tions required by the healthcare facility should be used. See
Appendix C for a list of commonly used abbreviations. To
facilitate quick data retrieval, data should be presented under
clearly marked headings, using the appropriate assessment
framework adopted by the healthcare organisation.
Whenever possible, subjective data should be recorded
using the person’s own words. Quotation marks should be
used: ‘I feel tired from the moment I first get up in the
morning. It seems I have no energy at all anymore.’ These
reports may also be paraphrased: ‘The person reports feeling
dyspnoeic, has difficulty catching breath when walking one
flight of stairs.’
The tendency to record data using non-specific terms that
are subject to individual definition or interpretation—words
like adequate, good, average, normal, poor, small, large—
should be avoided. One nurse or midwife’s sense of what
constitutes an average fluid intake may be very different from
that of another nurse or midwife. It is important to be specific.
Chapter 20 offers general documentation guidelines.
BOX 15-4 Legal alert
Nurses and midwives are responsible for alerting the
appropriate healthcare providers whenever assessment
data differ significantly from the person’s baseline, indi-
cating a potentially serious problem. Interventions for
which they may be legally responsible include increas-
ing the frequency of assessments and initiating necessary
changes in the treatment regimen.
Developing knowledge skills
In this chapter you have been learning about assessment as
part of the process of care. Once you have had the opportu-
nity to practise the process of person-centred care and carry
out assessments you will be more confident to practise these
identified skills and procedures.
What have you learnt?
•
Basic knowledge of how to complete an assessment
•
The ability to collect the appropriate data to complete an
assessment of the person
•
Knowledge of what constitutes accurate and appropriate
data for person-centred care assessment
•
Ability to understand and interpret the meaning of the
collated data
•
How to recognise actual and potential barriers to being
able to collect accurate and appropriate data for person-
centred care assessment.
To enhance your learning and facilitate further
understanding of this chapter, refer to thePoint
and LNPS online resources.
Developing critical thinking skills
1.
Working with another student, interview people in both
home and healthcare settings, and record your findings
separately. Make a list of the objective and subjective
data you gather on each person interviewed and the
inferences you make from these cues. Compare your
data lists and inferences. Describe to one another how
you plan to validate your inferences. Explore possible
reasons for the differences you discover.
2.
Allow another student to perform a comprehensive assess-
ment (interview and physical assessment) on you.
Reflect on what you experienced. Offer the student
feedback about which of their behaviours were helpful,
comforting or distressing. Change roles and talk about
what you learned from this experience.
3.
Collect several different forms for recording the
initial assessment (hospital, nursing home, home care,
and school of nursing and midwifery forms). Identify
and explain the differences you see. Experiment with
using the different forms and make a list of features
that help you get all the data you need in the easiest
way possible.
Review questions
1.
While administering a medication to relieve a person’s
pain, you wonder if there are some non-pharmacological
interventions that would enhance relief by complement-
ing the pain medication. When you discuss this with
your facilitator you are most likely to hear:
a. ‘You should wait until after you evaluate the effect
of the medication you just administered before
planning a different intervention.’
b. ‘One step at a time, dear. Don’t start planning a new
intervention until you evaluate the old.’
c. ‘Let’s talk about this … we often get new information
that we can incorporate successfully into the plan of
