Académique Documents
Professionnel Documents
Culture Documents
4 Types of Assessment:
Activities:
1. Collection of data
2. Validation of data
3. Organization of data
4. Analyzing of data
5. Recording/documentation of data
I. Collection of data
gathering of information about the client
includes physical, psychological, emotion, socio-cultural, spiritual factors that
may affect client’s health status
includes past health history of client (allergies, past surgeries, chronic diseases,
use of folk healing methods)
includes current/present problems of client (pain, nausea, sleep pattern, religious
practices, meds or treatment the client is taking now)
Types of Data:
a. Subjective data
also referred to as Symptom/Covert data
information from the client’s point of view or are described by the person
experiencing it.
information supplied by family members, significant others, other health
professionals are considered subjective data.
Example: pain, dizziness, ringing of ears/Tinnitus
a. Objective data
also referred to as Sign/Overt data
those that can be detected, observed or measured/tested using accepted
standard or norm.
Example: pallor, diaphoresis, BP=150/100, yellow discoloration of skin
V. Communicate/Record/Document Data
nurse records all data collected about the client’s health status
data are recorded in a factual manner not as interpreted by the nurse
record subjective data in client’s word; restating in other words what client says
might change its original meaning.
BIOGRAPHIC DATA
Includes client’s name, address, age, sex, marital status, occupation, religious
preference, health care financing, and usual source of medical care.
CHIEF COMPLAINT OR REASON FOR VISIT
The client’s answer to the question “What brought you to the hospital?” or “What is
troubling you?” is expressed in the client’s own words
PSYCHOLOGICAL DATA
These are major stressors experienced by the client and their perception of them, how
they cope up with these stressors, their communication to relay appropriate emotion.
PATTERNS OF HEALTH CARE
Includes all the health care resources that the client is currently using and has used in
the past.