Documenting and Clustering the Data

Data gathered during the interview and physical examination, and from other records/sources, are organized and recorded in a concise, systematic way and clustered into similar categories. Various formats have been used to accomplish this, including a review of body systems. This approach has been utilized by both medicine and nursing for many years but was initially developed to aid the physician in making medical diagnoses. Currently, nursing is developing and fine-tuning its own tools for recording and clustering data. Several nursing models available to guide data collection include Doenges and Moorhouse Diagnostic Divisions (Table 3.1),2,3 Gordon’s Functional Health Patterns,4 and Guzzetta’s Clinical Assessment Tool.