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Published on: January 16, 2019

Data collection and review in the delivery of safe care

Jane Ball

    Nursing Management (Harrow, London, England : 1994)
    |April 9, 2011
    PubMed

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    Data collection gathers information needed to make accurate judgments about a patient's present condition. During a health history interview, subjective data is collected from the patient, their caregivers, or family members, and objective data is collected through observations and physical assessment. Patients are the primary source of subjective data. Thus information gathered from patients through interviews, observations, and physical examination is primary data. Secondary sources of data...
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    Introduction to Documentation and Reporting01:20

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    Documentation is the systematic process of formally recording, maintaining, and communicating information.
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    Data Collection III01:05

    Data Collection III

    The physical assessment examines the patient for objective data that defines the patient's condition, and aids in formulating the nursing care plan. The purpose of physical assessment is a health status appraisal, which includes identifying health problems, and establishing a database for nursing intervention.
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    Purpose of Health Records I01:11

    Purpose of Health Records I

    The vital purpose of health records is to provide a complete and accurate account of a patient's medical history, including communication, diagnostic and therapeutic orders, care planning, research, and quality review.
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    Data Reporting and Recording01:24

    Data Reporting and Recording

    Reporting and recording are crucial in data documentation. The timely, thorough, and accurate documentation of facts is essential when recording patient data. Failure to record findings during an assessment or interpretation of a problem will result in loss of information and make the patient document unreliable. The reader is left with general impressions if the information is not specific. A recording is documenting data of the individual's health information in a traceable, secure, and...