HOW TO USE THIS COMPETENCY-BASED LEARNING

MATERIAL

Welcome to the Module in Presenting Relevant Information. This

module contains training materials and activities for you to complete.
The unit of competency “Present Relevant Information
” contains knowledge skills and attitudes required for Contact
Tracing Level II. It is one of the specialized modules at National Certificate
level (NCII).
You are required to go through a series of learning activities in order
to complete each outcome of the module. In each learning outcome are
Information Sheets, Self-Checks and Job Sheets. (Reference Materials for
further reading to help you better understand the required activities). Follow
these activities on your own and answer the self-check, perform the Job
Sheet using the Performance Criteria Checklist at the end of each learning
outcome. You may remove a blank answer sheet at the end of each module
(or get one from your facilitator/trainer) to write your answer for each self-
check. If you have questions, don’t hesitate to ask your facilitator for
assistance.
Recognition of Prior Learning (RPL)
You may already have some of the most of the knowledge and skills
covered in this learner’s guide because you have:
 been working for some time
 Already complete training in this area
If you can demonstrate to your trainer that you are already competent
in a particular skill or skills talk to him/her about having them formally
recognized so you don’t have to do the same training again. If you have a
qualification or Certificate of Competency from previous training, show it to
your trainer. If the skill you acquired is still current and relevant to the
unit/s of competency they may become part of the evidence you may
present to RPL. If you are not sure about the currency of your skills, discuss
with your trainer.
At the end of this module is a Learner’s Diary. Use this diary to record
important date, jobs undertaken and other workplace events that will assist
you in providing further details to your trainer or assessor. A Record of
Achievement is also provided for your trainer to complete once you complete
the module.

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 This module was prepared to help you achieve the required
competency, in. This will be the source of information for you to acquire
knowledge and skill into this particular trade independently and at your
own pace, with minimum supervision or help from your instructor.

 Talk to your trainer and agree on how you will both organize the
Training of this unit. The though the module carefully. It is divided
into section, which cover all the skills and knowledge you need to
successfully complete this module

 Work through all the information and complete the activities in

each section. Read information sheets and job sheets and complete
the self-check and perform the procedural checklist. Suggested
references are included to supplement the materials in this
module.

 Most probably your trainer will also be your supervisor or manager.

He / She are there to support you show you the correct way and
show you to do things.

 Your trainer will tell you about the important things you need to
consider when you are completing activities and it is important
that you listen and take notes.

 You will be given plenty of opportunity to ask question and practice

on the job. Make sure you practice your new skills during regular
work shifts. This way you will improve both your speed and
memory and also your confidence.

 Talk to more experience workmates and ask for their guidance.

 Use the self-check question at the end of each section to test your
own progress.

 When you are ready, ask your trainer to watch you perform the
activities outlines in this module.

As you work through the activities, ask for written feedback on your
progress. Your trainer keeps feedback/pre assessment reports for this
reason. When you have successfully completed each
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 element, ask your trainer to mark on the reports that you are ready
for assessment.

 When you have complete this module (or several module), and fell
confident that you have had sufficient practice, your trainer will
arrange an appointment with registered assessor to assess you.
The result of your assessment will be recorded in your
Competency Achievement Record.

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 LIST OF COMPETENCIES
Competency Unit of
Module Tittle Code
Number Competency

Participating in
1 Participate in workplace 400311210
workplace communication
communication

Working in team
2 Work in team 400311211
environment
environment

3 Solve/address Solving/addressing 400311212

General Workplace General Workplace
Problems Problems

4 Develop career Developing career 400311213

and life decisions and life decisions

5 Contribute to Contributing to 400311214

workplace workplace
innovation innovation

6 Present relevant Presenting 400311215

information relevant
information

7 400311216

Practice Practicing
Occupational Occupational
safety and health safety and health
policies and policies and
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 procedures procedures

Exercise efficient Exercising efficient

8 and effective and effective 400311217
sustainable sustainable
practices in the practices in the
workplace workplace

Practice Practicing
9 entrepreneurial entrepreneurial 400311218
skills in the skills in the
workplace workplace

MODULE CONTENT

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 MODULES OF INSTRUCTION

UNIT OF COMPETENCY: Presenting Relevant Information

MODULE TITLE : Present Relevant Information
MODULE DESCRIPTOR: This module covers the knowledge, skills and
attitudes required to gather, assess, record
and present data/ information appropriately.
NOMINAL DURATION: 8 hours

SUMMARY OF LEARNING OUTCOMES:

Upon completion of this module, the trainee/students must be able to:

LO 1. Gather data/ information

LO 2. Assess gathered data/ information

LO 3. Record and present information

ASSESSMENT CRITERIA:

1. Evidence, facts and information are collected

2. Evaluation, terms of reference and conditions are reviewed to
determine whether data/information falls within project scope
3. Validity of data/ information is assessed
4. Analysis techniques are applied to assess data/ information
5. Trends and anomalies are identified
6. Data analysis techniques and procedures are documented
7. Recommendations are made on areas of possible improvement
8. Validity of data/ information is assessed
9. Analysis techniques are applied to assess data/ information
10. Trends and anomalies are identified
11. Data analysis techniques and procedures are documented
12. Recommendations are made on areas of possible improvement

LEARNING
GATHER DATA/ INFORMATION
OUTCOME 1

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CONTENT:
1. Collecting data like name, age, history of present illness and
examination of signs and symptoms
2. Organizational protocols
3. Confidentiality
4. Accuracy
5. Business mathematics and statistics
6. Data analysis techniques/procedures
7. Reporting requirements to a range of audiences
8. Legislation, policy and procedures relating to the conduct of
evaluations
9. Organizational values, ethics and codes of conduct

ASSESSMENT CRITERIA
1. Evidence, facts and information are collected
2. Evaluation, terms of reference and conditions are reviewed to
determine whether data/information falls within project scope

CONDITIONS:

The following resources must be provided:

Writing materials
References
Manuals
Computer and Printer
 Internet connectivity
METHODOLOGIES

 Online learning
 Offline learning
 Group discussion
 Lecture
 Demonstration

ASSESSMENT METHODS:

 Online/Virtual Assessment
 Interview

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 Written test
 Observation
 Presentation

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 LEARNING EXPERIENCES

Learning Outcome # 1

GATHER DATA/INFORMATION

Learning Activities Special Instruction

1. Read Information Sheet 6.1-1

on Collecting data like name,
Compare answers with Answer Key
age, history of present illness
and examination of signs and 6.1-1
symptoms then answer Self-
Check 6.1-1
2. Read Information Sheet 6.1-2 Compare answers with Answer Key
on Organizational protocols 6.1-2
then answer Self-Check 6.1-2
3. Read Information Sheet 6.1-3 Compare answers with Answer Key
on Confidentiality then answer 6.1-3
Self-Check 5.1-3
4. Read Information Sheet 6.1-4 Compare answers with Answer Key
on Accuracy then answer Self- 6.1-4
Check 6.1-4
5. Read Information Sheet 6.1-5
Compare answers with Answer Key
on Business mathematics and
statistics then answer Self- 6.1-5
Check 6.1-5
6. Read Information Sheet 6.1-6
Compare answers with Answer Key
on Data analysis
techniques/procedures then 6.1-6
answer Self-Check 6.1-6
7. Read Information Sheet 6.1-7
Compare answers with Answer Key
on Reporting requirements to
a range of audiences then 6.1-7
answer Self-Check 6.1-7
8. Read Information Sheet 6.1-8 Compare answers with Answer Key
on Legislation, policy and 6.1-8
procedures relating to the
conduct of evaluations then
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 answer Self-Check 6.1-8
9. Read Information Sheet 6.1-9
Compare answers with Answer Key
on Organizational values,
ethics and codes of conduct 6.1-9
then answer Self-Check 6.1-9

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 INFORMATION SHEET 6.1-1
Collecting Data Like Name, Age, History of Present Illness and
Examination of Signs and Symptoms

Learning Objectives: After reading this INFORMATION SHEET, you MUST

be able to:

1. Identify the different datum needed for the patient’s information

2. Know how to properly collects datum of the patient.

INTRODUCTION
Traditionally among medical practitioners (doctors), the process at the very
beginning of care is termed as “clerking”. This consists of “history taking”
and “physical examination”. Other clinical care providers e.g. nurses use the
term ‘assessment’. It must be realized that this process is the start of a data
management cycle which consists of:

1. Data collection / gathering

2. Data Capture
3. Data Storage
4. Data transfer / dissemination
5. Data Use i.e.:
 extraction
 aggregation
 analysis
 interpretation
 presentation (display)
When data is recorded on paper, the act of writing in ink captures the data.
The entries are somewhat indexed as lines, pages, files and folders with
paper as the storage medium. Data is disseminated by making the folders
available at the point of care. The record is then perused and interpreted by
the clinician.

At present computerized information systems are available to perform these

processes in a more organized manner leading to enhanced benefits. Data
capture is done through typing on a keyboard, selecting using a pointing
device or scanning. Data is properly indexed and stored in a database.
Users view the data on a computer screen. Data is distributed via a network
allowing many persons to view it simultaneously.

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Actually, information is generated and utilized at every step of the clinical
care process including the activities of investigation, observation,
monitoring, diagnosis, planning, treatment and review. Clinicians also
record their plans, orders, procedures performed, observations, test results,
opinions and discussions. Also, unplanned events (incidents) are recorded.
Often, this is considered as ‘clinical documentation’.

DEPENDENCE OF CLINICIANS AND CLINICAL PRACTICE ON DATA

Clinical care processes are iterative or cyclical in nature i.e. the processes
are repeated as and when necessary. Therefore, as subsequent work
processes are performed more information are generated.

Clinicians (i.e. all professionals involved in direct patient care) are very
dependent on data already available to perform their work. Therefore, from
this perspective clinical care processes should be considered as a series of
data / information management activities. Being able to access to
accumulated data is indispensable because a large part of clinical processes
are cognitive (thinking) processes with data being the main input and
output.

This article discusses the process of information gathering in general and

specifically, data gathering at the initial part of care. Data collection for
purposes of monitoring, diagnosis, treatment planning, monitoring and
progress review and assessment are discussed in separate articles dealing
with them.
The term “initial” is applied to the first encounter of a patient with a doctor
or any other health care provider of the clinic or hospital regardless of
whether he/she is a walk-in patient or a referred case. The difference is that
if assessment, observation and treatment had been performed previously,
the results are usually available in the referral letter and can be termed as
data originating from elsewhere.

At subsequent interaction with the patient (encounters) data is continually

collected for purposes of monitoring, progress review and evaluation.
BUILDING A PROFILE OF THE PATIENT

Patient care is not just about treating the disease but the patient as a
whole. Therefore, there is a need to have sufficient information regarding the
patient to allow for special considerations to be made in making decisions,
implementation of management plans, communications and imparting
information.

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 Identification
It is important to identify the patient with certainty so as to ensure that:

a. The right process is performed on the right patient

b. The patient’s data is assigned to the right entity in the common database
and subsequently to the right medical record/li>
A patient is usually identified by his/her name. However, this is often not
unique enough as persons can have the same name. It is the practice in
health care to assign a serial non-repeated number to the person (Medical
Record Number or Patient ID). If there is an existing unique personal
identification number like National Registration Identification number, this
may serve the same function alternatively or be the secondary identifier.
Some characteristics of the person must be known before this unique
number is given. Subsequently, confirmation of identity is based on a set of
data rather than one data element. These characteristics include a
photograph, gender, age, ethnic origin and home address.

Demography, Anthropometry And Social Background

Demographic data such as age and gender have other uses besides
confirming identity. Anthropometric data such as height, weight and body
surface area allow for the patient to be grouped into physiologic categories.
They can be used to calculate certain parameters and allow comparison
with expected standards e.g. body mass index and growth percentile or
doses such as requirements for dietary intake, fluid, drugs and radiation.
Other parameters like educational level, ethnic origin, languages spoken,
occupation and location of abode, give an idea on the social background of
the patient enabling the care provider to understand how the illness affects
the patient’s life and his ability / willingness to comply with treatment
programs.

Acquiring Complete Information Re: Health Status

The total care of a patient cannot be achieved by knowing the diagnosis of
the present illness alone. The clinician needs to know the health status of
the patient before and immediately after he/she is affected by the illness.
With this information, he/she is better able to determine the severity of the
effect of the disease on various physiologic systems and subsequently to
provide supportive therapy.

Pre-Morbid Health Status

It is good to know the health status of the patient before he/she is affected
by the illness. An important aspect is the nutritional status. Other aspects
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 include level of physical activity, social interaction and psychological
outlook. In children, the developmental status may contribute to or affect
the current illness. Most importantly pre-existing illnesses including chronic
diseases and unresolved previous illnesses or injuries need to be carefully
evaluated. The care provider must be aware of whatever treatment that the
patient is receiving currently, especially drugs and how well these have
controlled the effects or modified the course of the illnesses.

Psycho-Social Status
The patient’s psycho-social status and level of education needs to be
gauged; because these will impact on his/her understanding of the illness
and its management. It would also make it easier for the care provider to
communicate with the patient and ensure that the patient accepts, complies
with and is satisfied with various aspects of care given.

CREATING A RECORD OR LOG OF EVENTS

Based on professional and legal requirements, clinicians must capture and
store data regarding events or incidents experienced by the patient and the
processes performed in managing him/her. The greater part of the stored
data is designated as being part of the Medical Record. The clinician also
needs to record the intended case management objectives and plans.
Recorded data can be used for quality control and for ensuring continuity of
care. The data regarding a patient or the aggregated data of a group of
patients is valuable for administrative reviews or audits, inquiries, quality
measurement, learning activities and research. Recording the data is also
necessary for legal and professional purposes to demonstrate transparency,
accountability, compliance with regulations and conformance to
professional ethics. The medical record should also make evident the roles,
responsibilities of various care providers vis-a-vis the patient and also the
relationships between the care providers.
The data in the Patient Information Database and subsequently the medical
record is arranged in chronological order and grouped according to periods
such as episodes, visits, encounters and events (planned and unplanned).
Some auxiliary data need to be collected and recorded as well. These
include:

i. time & period (beginning and end of an encounter, duration of

transactions)
ii. sequence,
iii. context, occasion,
iv. location
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v. identities of persons involved
Mechanisms must be in place to record tasks performed and the results
either manually (via forms and charts) or automatically when those are
performed by machines .

Care Episodes And Phases Of Care

For better understanding, the period within which care is given can be
divided into

A. Episodes,
B. Phases,
C. Visits,
D. Encounters
E. Events

The Care Episode

A care episode is defined as the period within which the management of one
particular disease or a health problem affecting a patient takes place i.e.
beginning with the time of first contact with a health care practitioner to the
termination of care due to resolution of the illness/problem, the patient’s
decision to discontinue or death of the patient. During an episode, the
patient may make several visits and during each visit he or she may
encounter many health care providers, subjected to many care events or
experience certain incidents.

Phases Of Care
The care episode can be divided into phases of the various care delivery
process. The phases can be categorized loosely into:

1.Phase of diagnosis or problem identification and elaboration

2.Phase of initiation of treatment and adjustment of therapy
3.Phase of maintenance of therapy, monitoring, review and adjustment
of the care plan and therapeutic strategies
4.Phase of assessment of effectiveness and continuation-termination of
therapy
The duration of each episode is variable. It can be limited to one day or even
a lifetime. It would not be uncommon for all the phases to be completed
within the same day. For incurable diseases, the fourth phase may
terminate only with the patient’s death.

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 Visits, Encounters And Events
A clinical visit begins when a patient presents him/herself to a health care
service facility and ends when he/she leaves it. It can be to any one of
various care settings including Outpatient, Daycare, Inpatient or
Teleconsultation. A home visit is also a visit.

Services are provided by Clinical Service Units belonging to Clinical

Departments. Each visit consists of various encounters with a care provider.
During an encounter, the patient receives part or all of the clinical care
services. These include planned events such as consultation, performance
of diagnostic procedures (investigations), monitoring, treatment, nursing
care and other clinical activities. The patient may be involved unplanned
events (e.g. incidences, complications and another illness).

DATA GATHERING METHODS AND DATA SOURCES

DATA GENERATION
Data arise when certain processes are performed or events happen. In
clinical practice, data is generated by the following basic actions:

a. Acquire from existing sources

b. Interview
c. Observe
d. Inspect
e. Count
f. Measure
g. Examine
h. Test
i. Capture of data generated by machines
j. Manipulation of existing data (calculate, compute, analyze, interpret and
conclude)
All clinical care processes generate data. Clinicians obtain the data, record
them as notes, results or charts by performing the processes listed below.

1. Interview the patient (history taking)

2. Perform a physical examination
3. Perform simple clinical tests
4. Perform investigations including laboratory, imaging, endoscopic and
others
5. Review available data, determine the diagnosis and plan the case
management
6. Implement care as planned
7. Monitor and assess the patient
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Machines when used to perform functions like tests and monitoring also
generate data.

In a paper record the documented information is compiled in a file, in

chronological order and appears exactly as they are written. In a
computerized system, besides keeping it as a chronological record, the data
may be categorized, indexed, put together and displayed as views that
serves specific purposes.

CHOICE OF METHODS
How and when data is gathered depends on the situation and type of case.
The sequence need not necessarily follow the standard clinical workflow
described above. Sometimes opportunities arise unplanned, e.g. a patient
describes something that the care provider intends to ask later or a sign of
another area is noticed when examining a certain area. However, the way
the data is presented need to follow a standard format so that information
can be easily sought and understood by everyone involved in the care of the
patient.

At the first encounter, the crucial reason for gathering data is to obtain
sufficient information to make a diagnosis and act upon it.

In emergency situations, there is a need to identify the problem quickly.

Often the physical examination is performed before history taking.
Sometimes, a biochemical test (e.g. blood sugar level using a point of care
testing method) is done straight away. Using a Pulse Oximeter to determine
the oxygen saturation of the peripheral blood (SpO2) is another example.
However, subsequently a complete history need to be taken and a full
examination performed to derive a more accurate and comprehensive
diagnosis and to get to know more about the patient.

Information gathering is a continuous process. All clinical processes

generate data. The process itself often determines how data is collected.
Unexpected events or incidents and their effects need to be described as
they happen. Yet some active data gathering need to be done to ascertain
what actually happens, where, who are involved and the reasons why they
occur. The experienced clinician would be aware which data need to be
recorded for immediate use and which will be required for later use. The
need for some data becomes obvious only when the occasion arrives. For
example, when using a drug to treat a disease some information may be
required regarding allergy to drugs or the patient’s preference.

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 Computation, analysis and interpretation of existing data results in new
(derived) data. This facility can be used to derive scores or assign patients to
predetermined groups for purposes of severity grading, risk assessment and
prognosis.

CONTENT AND CHARACTERISTICS OF DATA

Content
The data regarding the patient includes:

1. Symptoms experienced by the patient or observed by people close to him

and on-lookers
2. Signs discovered or elicited by the care provider
3. Observations made by qualified care providers
4. Parameters measured by monitoring equipment
5. Results of clinical tests
6. Images from imaging examination & reports made
7. Physiological tests
8. Laboratory tests
I. Biochemistry
II. Immunology
III. Microbiology
IV. Haematology
V. Histopathology and Cytology
VI. many others
Data Characteristics
Subjective Data
Information provided by the patient and their carers though subjective is of
paramount importance because it describes personal experiences including
past events, not obtainable from any other source. It is also the means for
the patient to express his/her problems and needs. However, the clinician
should be aware that some of the information provided is inadequate or may
not be very reliable. Occasionally patients hide the truth or make up stories.

The patient’s description of the sequence of events enables the care provider
to compare it with the natural history of a known disease. This will aid in
determining diagnosis, stage of the illness and its severity.

Objective Data
The care provider must attempt, to the utmost possible, to obtain objective
information through the use of more reliable methods such as physical
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 examination (direct observation, palpation, auscultation etc.) and tests.
Usually, the diagnosis becomes increasingly more accurate as care
progresses as more objective data are obtained from monitoring and
investigations. Tests that give specific objective information regarding a
disease and used to clarify the diagnosis are called diagnostic
investigations.

DATA FROM EXISTING SOURCES

REVIEW OF PAST RECORDS

It is mandatory for the clinician to establish whether the patient has
received care before the visit. If it is from the same hospital or clinic, the
patient’s medical records (paper or electronic) should be retrieved and
reviewed. Valuable information can be obtained regarding previous episodes
of illness, visits or encounters. A visit summary or discharge summary
written by the care provider managing the patient during encounter, visit or
episode, if available, is invaluable for ensuring effectiveness, continuity and
safety of care.

ACCESS TO DATA FROM OTHER FACILITIES AND CARE PROVIDERS

The patient seeking a consultation may bring along information regarding
care in the health care facility where they were previously managed in the
form of:

1. Referral letters,
2. Notes / printouts of results and reports (Histopathology and Radiology
Report)
3. X-ray Films or Images in digital format
4. Case summary
5. Patient carried records
Information from these documents should be incorporated into the patient’s
history. It is also important to retain original hard copies or digital scanned
images of them.

INTERVIEWING THE PATIENT

Interviewing the patient (taking a history) is an activity of obtaining
information for some of the purposes mentioned earlier and elaborated
below. The data includes:

1. Data regarding Identification, demographics and social background

2. History of present illness
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3. Complete information regarding the health status of the patient including
past illnesses
4. Information regarding the patients understanding of his/her illness and
attitude towards it
METHOD
Identification, Demographics & Social Background
Much of the data regarding identification, demographics and social
background would have been recorded by clerical staff at the time of patient
registration. The clinician, however, needs to verify that these are accurate
and add on whatever appears to be relevant.

History Of Present Illness

The main purpose of the interview is to obtain the history of the present
illness. “History” here denotes happenings that the patient or others are
aware of, occurring over a time period. It has two elements i.e.

1. Sequence of events (happenings)

2. Symptoms
To any person, being sick is an occasion when he/she experiences one or
more symptoms or notice something unusual about him/herself. The onset
of the illness may be heralded by an event which may be its cause, for
example an injury. It may actually be the effect, for example a fall after
losing consciousness. Often the event is not related to the illness but the
patient may think otherwise.

By taking a clear history of the symptoms and the events surrounding it,
the clinician hopes to know the following:

1. The manifestations and development of the illness, hence to determine the

most likely pathology or disease causing it (the diagnosis)
2. The existence and severity of symptoms and the need for relief
3. The extent of disability or impairment of function (physical, psychological,
social and spiritual) and the need to restore it
4. The patient’s insight into his/her illness

The Asymptomatic Patient

Sometimes patients who seek care may not have symptoms. Patients may
turn up because they are worried or suspicious (e.g. a disease that runs in
the family), after doing a test voluntarily or as part of a screening
programme. A review of symptoms of various systems still needs to be
done.

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 Clarifying The Sequence Of Events
The habit of asking the patient ‘Why do you come to the hospital?’ is
unhelpful and confusing to the patient. The most likely answer that will be
obtained would be “I come to get treatment” or “I come to see the doctor”. In
Western culture perhaps it’s a social custom to say “My dear, what brings
you to see me?” or “To what, do I owe the honour of this visit?” and it would
be clearly understood by the patient. It does not work so well in other
cultures.

Instead, it would be better to ask the patient directly “When did you first feel
unwell?” followed by “What make you think so?” Depending on the type of
symptom and acuteness of the onset the patient may give an exact time or
some vague period. The patient may even say he/she is healthy except for
the appearance of some swelling or mass or other changes in appearance
which is noticed either by himself or people around him.

Understanding The Natural History Of A Disease

The natural history of a disease refers to development of a disease over time,
without medical intervention, characterized by the pathogenesis, the
different effects it has on the patient leading to various clinical
manifestations, progress and endpoints. A disease’s presentation is often
typical but atypical presentations do occur. The overall pattern of progress
may be described as:

1. Symptoms increasing or decreasing in severity

2. Episodes vs. Disease free periods
3. Attacks or Exacerbation vs Sub-clinical presentation,
4. Remissions vs. Relapses, Recurrences of previous illness
Patients seek treatment at different stages of their illness.It is not sufficient
to understand only the “classical” presentation of an illness but also the
different modes of manifestation at the different stages.

Symptoms: The Manifestations Of Illness

A disease often manifests as a set of symptoms (the symptom complex) that
is often characteristic. The more serious or prominent complaints are
termed as the main or chief complaints. Information need to be obtained
regarding each symptom separately; but knowing the relationships of the
symptoms (the symptom complex) is just as important. In taking a history,
the clinician attempts to establish the development of the disease over time.

Onset, Development And Duration Of Illness

By knowing the symptoms and their development, the clinician is able to
relate the illness with known pathological processes. It is important to
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determine when a symptom actually starts (onset) and whether it is
triggered by an event. Symptoms that appears and progresses slowly at the
initial stage is said to be insidious in onset and relate to a disease that
develops gradually. Symptoms sudden in onset are usually indicative of
acute illness caused by pathologies that develops quickly such as acute
inflammation, obstruction, perforation, sudden ischaemia, bleeding or
trauma.

It is important to determine when the illness actually starts. From the

patient’s point of view, the duration of the illness is from the time the first
symptom starts to the time he/she has an encounter with the clinician.
He/she may be aware of other episodes or other similar symptoms but may
not relate them to the current illness. The clinician need to ask the patient
about any changes to his/her health during the period prior to the illness.
The duration of illness is a major factor in determining severity of illness. As
a rule, the severity of symptoms especially the development of complications
increases with duration. Yet, there are instances where time has allowed the
healing processes to proceed and symptoms have become reduced or
altered. This may not mean that the disease has healed or aborted.

The duration taken to seek treatment reflects on the patient’s attitude to

illness and medical care. This knowledge is of use to the care provider in
determining the right approach to the patient.

Progress Of Symptoms
The occurrence of symptoms reflect the progress of the disease. A set of
symptoms may occur for a certain period and then abates before occurring
again at another period. Each period can be thought of as an episode of the
illness and the illness is said to be episodic or recurrent (note that the
disease episode is different from the care episode). Patients often do not
consider milder symptoms to be part of the same illness. It is likely that the
illness may have occurred earlier than the patient’s own estimation.

If the symptoms of a chronic illness become dormant, mild or infrequent for

a considerable period, the illness may be considered to be in remission. If a
disease remains but does not manifest in symptoms it is said to be sub-
clinical. If a patient develops symptoms again after the illness is thought to
have been cured, the new episode may be considered as a relapse or
recurrence. An attack or exacerbation is said to occur if after being sub-
clinical, symptoms become suddenly perceptible, worrisome or worsened.
Many diseases are episodic in nature i.e. periods of remission are followed
by recurrences (e.g. migraine).

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In an acute illness, a symptom may vary in intensity (wax and wane). It may
appear and then fade only to appear again after a short duration (said to be
intermittent). It may also disappear completely for a significant interval but
appears again with the same intensity (said to be remittent)

The essence of history taking is relating events and symptoms to time. As a

basic requirement, the clinician needs to possess theoretical knowledge
regarding the natural history of a disease i.e. the development of a disease
without medical intervention and the different possible effects it has on the
patient over time. It is important to know whether symptoms occur
simultaneously or sequentially and whether they are continuous or
recurrent. The clinician is then able to relate the various clinical
manifestations, complications, progress and endpoints with pathogenesis of
the disease. It is good to know if the patient has taken some medication on
his/her own or has obtained some sort of treatment elsewhere because
these will alter the manifestation of the symptoms.

Often, patients volunteer information regarding their previous encounter

with other care providers. They may also provide the diagnosis and describe
findings of tests performed. The clinician should make a note of these but
should take his/her own history and make his/her own conclusions.

Disease Episode and Care Episode

Disease Episode and Care Episode

Morphologic And Physiologic Effects

Symptoms can be felt in a specific organ, at an anatomic region or generally.
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The anatomical location of the symptom may give an idea of the organ or
organs involved. It may suggest the tissue type involved e.g. whether it is
skin, muscle, nerve or blood vessel. Symptoms may also relate to a
particular physiologic function. It may also indicate the probable pathology.

General/Systemic Symptoms
General symptoms are usually manifestations of the derangement of one or
more physiologic systems. It is expected even if the disease is in a specific
organ. Therefore, if symptoms expressed by the patient appear to be
confined to an organ or site, the general symptoms expected with the
pathological process or malfunctioning of the organ should be looked for.
Diseases originating from an organ may have spread or extended to the
surrounding region by the time the patient seeks help. The history becomes
the means for the clinician to ascertain the beginnings of the disease.

Symptoms Of Specific Organs And Sites

It would be desirable for the clinician to be able to work out a postulate of
the site of illness, the physiological system or organ affected and the
aetiology based on the symptoms. This requires a good knowledge of
regional anatomy and physiology.

The Symptom Complex

An illness may manifest as a single symptom or a set of related symptoms.
Besides describing each symptom according to the characteristics
mentioned earlier, the composition, association and relationship of
symptoms need to be clarified. A set of symptoms, occurring together is
termed as a symptom complex. The combination is dependent on the
anatomic site, physiological system affected and pathological process and is
often typical for a particular disease or disease group. termed clusters.
Symptoms can appear concurrently or sequentially. The order and interval
of appearance of symptoms are important indicators of the nature of the
illness as is their progress and remission. A set of symptoms appearing
within a short period is often called a cluster.

Further reading: link

INFORMATION THROUGH PHYSICAL EXAMINATION

PURPOSE OF PHYSICAL EXAMINATION
The main purpose and objective of a physical examination is to discover
changes in:

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1. The morphology (appearance) of the whole patient, relevant anatomical
regions and organs
2. The physiologic functions of various systems or organs
In doing so the clinician also establishes whether there are variations of
these from normal and confirms those that are normal or probably
unaffected by the illness.

APPROACH TO PHYSICAL EXAMINATION

The clinician can take two approaches to physical examination i.e.:

1. Examination based on Postulate or Hypothesis derived from History of

Illness
2. Systematic Review
Each approach has its merits and a combination of both is the right
approach. In a situation where initiation of treatment need to made quickly,
a quick examination of the part or system that would provide the most
useful/relevant information to make a diagnosis and assess the patient,s
condition should be done. A more complete examination can be performed
when the patient is more stable.

In a less urgent situation, a complete examination is performed from the

start. The luxury of ascertaining the morphology and function of various
organs and system without missing less obvious signs, will facilitate the
derivation of an accurate diagnosis

Method
Findings on examination are often referred to as signs. They can be either
discovered or elicited. The astute clinician uses all his/her senses of the
examiner (sight, touch, smell and hearing) with the exception, perhaps, of
taste.

The methods used in physical examination are:

1. inspection and observation

2. palpation
3. percussion
4. auscultation
Using Clinical Tests To Elicit Signs
Clinical tests are used to determine whether the patient’s response to
stimuli is normal or abnormal. Such tests use various mannoeuvres or
manipulations and stimulation of the patients with physical agents,
situations or drugs. Tests may assess behaviour, functions and
characteristics.
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 (details are best obtained from books on Clinical Methods.)

Examination Guided By Symptoms

When substantial facts have been obtained through history-taking, then it
is possible for the clinician to consider the illness and its causes as a
postulate or hypothesis and use it as the guide as to the signs he/she
should be looking out for. Hence, the areas to be examined and the signs to
look for are those expected in that particular syndrome or disease. A good
knowledge of the common manifestations of the disease being suspected is
essential.

Note that failure to find the signs do not disprove the hypothesis because
some effects of illness are especially at the early stage are subtle and may be
detected only by various laboratory-based tests, imaging techniques,
endoscopy or modalities. Repeat examination at a later time may prove to be
useful.

THE CLINICAL SYNDROME

Signs also often manifest as a set. These taken together with the set of
symptoms, constitutes a ‘Clinical syndrome’. By knowing how various
diseases manifest, the clinician can determine which anatomical site and
physiological symptom to concentrate on.

GENERAL EXAMINATION
In the general examination, the patient as a whole is assessed. It is used to
seek the following:

1. The manifestations of the changes in the health status of the person as a

whole
2. The obvious or easily obtainable signs relating to various physiologic
systems i.e. cardiovascular, respiratory, neurologic, renal, and
musculoskeletal systems
Being a general examination, it is not meant to be use to elicit signs
regarding a particular organ. It is incorrect to begin by saying “on
examination of the hand”. Instead the correct expression is the “peripheries
are warm” after examining both the fingers and toes. Pallor can be a result
of reduced haemoglobin, decreased oxygen saturation or poor perfusion. It
should be described as “the conjunctiva, mucous membranes and fingers
are pale”, instead of saying “on examination of the eye: the conjunctivae is
pale”. It is not an eye examination, it is a general examination.

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 Generally, each system is characterized by a typical set of signs. However, a
sign may emerge as a result of derangement of different different systems or
due to different disease processes.

SYSTEMATIC REVIEW
Signs may be present even if the there is no related symptom. This may be
because the patient was unaware of it or would not divulge its presence.
There are also signs that appear before symptoms arise. An alert clinician
should be able to discover these signs as part of a systematic review. This
consists of examining each region and system in turn to discover anomalies.
It may not be detailed and exhaustive initially but may have to be repeated
later if the diagnosis remains unclear.

Hence, despite the postulate made after history taking the clinician needs to
have an open mind and consider all possibilities. The discovery of one or
more signs will lead to a different postulate and signs expected of that
postulate should be looked for. Indeed, the patient should be queried about
the presence of the sign and would often then recall symptoms or events he
or she had not mentioned earlier.

METHOD OF PHYSICAL EXAMINATION

When performing the physical examination, the clinician uses various
senses to discover the morphologic appearance or physiological status of a
patient. These include the use of:

1. Sight: to inspect the morphology (colour, shape) and observe the

physiology (movement)
2. Sensation: to determine texture, consistency, vibration, temperature, etc)
3. Hearing: to listen for normal and abnormal sounds
4. Sense of smell: to detect abnormal odour
Inspection
To inspect means to look once but thoroughly. The parts or organs to be
inspected need to be exposed. The purpose is to detect changes in the
appearance of visible organs or body regions including skin, mucous
membranes, appendages and protruding organs. Although only superficial
parts can be inspected, deductions can be made regarding deeper
structures or certain functions (e.g. ptosis due to inability to move eyelid).

The characteristics of each organ or part to be inspected include:

 Colour
 Surface appearance
 Shape
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 Rough Size
 Abnormal or additional features not seen when the organ is normal (e.g.
discharge)
The clinician seeks for and describes the difference in these features from
that expected of a normal person. Both inspection and observation are best
done first without prior disturbance or interference. In children, this may be
best done when they are asleep or are distracted.

Observation
To observe is to look for changes in function and appearance of an organ or
body region over a time period. The functions that may be observed include:

1. Overall demeanour, facial expression, gait and posture

2. Conscious level (speech, spontaneous movements)
3. Movement (limbs, lips, eyelids, nostrils, the head)
4. Breathing
5. Beating of the heart
6. Pulsation of arteries
For functions occurring at a regular frequency (breathing, heart beat and
pulsation), the rhythm and intensity can be observed and the rate counted.
Test of Function by Observation

Some functions are not evident by passive observation but can be made
apparent by instructing the patient to perform certain maneuvers. This
purposeful performance (e.g. movement) is said to be “active” function.
These are actually tests to demonstrate ability or disability of certain
functions (e.g. opening eyes and moving them side to side / up and down).

Palpation
Palpation is the use of tactile sensation of the fingers and hand to detect
characteristics that include:

1. Change in temperature
2. Surface texture
3. Shape
4. Contour or edge
5. Extent or size
6. Consistency
7. Mobility
8. Spontaneous movement of organs
9. Location, depth and relationships

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The act of palpation itself can also act as a test e.g. of tenderness and
mobility.

Only signs in organs accessible to the fingers can be elicited. A gentle light
superficial palpation gives different information from deep palpation. A
knowledge of surface anatomy helps in determining the likely organs from
which the signs originate. The knowledge of cross-sectional anatomy help
indicate which anatomical layer the lesion is located i.e. within the skin,
subcutaneous tissue, the muscular layer, bones or body cavities. Certain
characteristics such as extent can be inferred when even when the whole
organ or mass cannot be reached based on the clinician’s knowledge of
anatomy or physiology.

In deep palpation the force exerted should not exceed that which would
cause discomfort to the patient and he/she should be forewarned. The
presence of tenderness should be anticipated and the presence of pain
should be asked for from the patient. Light palpation may be performed in
the presence of slight tenderness and the patient should be warned
regarding it. No further palpation or percussion should be done in the
presence of tenderness. The clinician will have to use other means such as
ultrasonogram or examination under anaesthesia to elicit the signs.

Local, Regional And Generalized Changes

Examine

Test

Morphologic changes brought about by illness can be local regional and

generalized. General physiology

General morphology

Specific finding

Location, extent

Characteristics

Specific function

Specific morphology
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 The mass or swelling

Examination of regions and organs

Examination of physiological systems

A Set Of Signs And Symptoms: The Syndrome

A set of associated symptoms and signs occurring together is termed as a
syndrome It is often typical of a particular disease or disease group.. Again,
like the symptom complex, the combination is dependent on the anatomic
site, physiological system affected and pathological process and

DOCUMENTATION OF DATA: CONTENT AND CHARACTERISTICS

The way data obtained from interview, examination and clinical tests as
recorded on paper has evolved from an unstructured to more structured
formats. In earlier times care providers write on a blank sheet of paper and
records whatever they think are important findings. Later, they may follow a
certain order such as SOAP i.e. subjective data (from the interview),
objective data (from physical examination and tests), assessment (actually
formulation of diagnosis) followed by plan of care. Further to that, if the type
of disease and the region or system involved is known then the data
elements and even the results for anticipated findings may be pre-printed
for the care providers to fill in.

Even when computerized forms may take on the form of empty pages, with
or without headings, where data can be typed in However, the use of
electronic forms for data acquisition allow for the structure to be more
definite and content to be more relevant. The use of structured data allow
for data aggregation, analysis and interpretation, features that can enable
the provision of decision support. This is further discussed in the article
on Clinical information System under the topic on data acquisition.
More complex forms can be structured such that documentation follows the
data gathering processes performed by the care provider. The data can be in
compartments arranged in a certain order applicable to history taking and

For physical examination it may have the structure as below:

1. General morphology
2. Specific finding
a. surface appearance (colour, texture, breach of skin, discharges)
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 b. tenderness,
c. presence of mass etc.).
For each of these, means of documenting expected characteristics can be
provided such as:
 Location, extent
 Specific function
 Specific morphology
 The mass or swelling

INFORMATION FROM CLINICAL TESTS

OBJECTIVE
Simple or requires use of instruments.

Need some degree of expetise

METHOD
choice

CONTENT AND CHARACTERISTICS OF DATA OBTAINED

1. of care including performance of procedures and use of drugs
2. To monitor and assess the progress of the illness, the effectiveness of
treatment and the side effects of treatment
as in patient interview and physical examination. Routine tests are
confined to only uncomplicated and inexpensive investigations.

1. Culture for organisms and tests for immune responses

2. Biopsies (cytology and histopathology)
3. Specific chemical tests

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 Self-Check 6.1-1
Identification: Read each sentence below and analyze what is being asked or
described.

1. Datum such as age and gender have other uses besides

confirming identity.
2. Data such as height, weight and body surface area allow for
the patient to be grouped into physiologic categories.
3. The health status of the patient before he/she is affected by
the illness.
4. Status and level of education needs to be gauged; because
these will impact on his/her understanding of the illness
and its management.
5. Is defined as the period within which the management of one
particular disease or a health problem affecting a patient
takes place i.e. beginning with the time of first contact with a
health care practitioner to the termination of care due to
resolution of the illness/problem, the patient’s decision to
discontinue or death of the patient.
6. Begins when a patient presents him/herself to a health care
service facility and ends when he/she leaves it.
7. Information provided by the patient and their carers though
subjective is of paramount importance because it describes
personal experiences including past events, not obtainable
from any other source.
8. Patients who do not experience any signs or symptoms.
9. Means to look once but thoroughly.
10. Is to look for changes in function and appearance of an
organ or body region over a time period.

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 Answer Key 6.1-1
1. Demographic date
2. Anthropometry data
3. Pre-morbidity status
4. Psycho-social status
5. Care episode
6. Clinical visit
7. Subjective data
8. Asymptomatic patient
9. Inspection
10. Observe

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 INFORMATION SHEET 6.1-2
Organizational Protocols

Learning Objectives: After reading this INFORMATION SHEET, you MUST

be able to:

1. Identify what is organizational protocol

2. Described the different company protocols and procedures.

Protocols and procedures are the specific way that a policy, rule or principle
is carried out. It can often be thought of as a set of instructions. Procedures
can help small businesses to function productively by ensuring that
everyone executes tasks in the same way. It can be beneficial for
organizations to review their protocols and procedures on an annual basis to
ensure that they are up to date and reflect current business objectives.
Developing protocols and procedures is a matter of understanding the
company’s direction and goals.

How to develop a protocol

Identify the policy or rule that needs a procedure attached to it. Clearly
understand the goal of the policy, such as if it is solving a problem,
increasing productivity, ensuring quality of a product or service, or if it is
preventing a potential conflict. Consider similar protocols that have been put
in place in the past and determine if they can be used as models for this
particular issue.

Determine if your management or staff needs to acquire any additional skills

or equipment to complete the procedure. For example, the procedure may
involve scanning documents for electronic files so that you are able to do
away with paper files. Therefore you may need to purchase a scanner and
then train particular staff members on its operation methods. Additionally,
you may need a companywide document distributed explaining how
employees are now able to access the electronic files.
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3

Document the procedure in a step-by-step format. Make sure the

instructions are clear and easily understood by the various people who will
need to follow the protocol. Use layman’s terms whenever possible to
eliminate any potential confusion.

Test the protocol out. Distribute the instructions to a test group of three to
five people and have them put the procedure through a trial run. Ask them
to document any problems that they encounter while executing the protocol.
Have them make suggestions on ways to improve the instructions or
methods.

Review the test group’s findings and notice any problems or challenges with
the procedure. For example, the test group may have noticed that gridlock
will be created if your company purchases only one scanner since numerous
people will be using it. Amend the protocol as necessary.

Finalize the protocol and submit it to management for approval. Gather

feedback from your supervisors and make any needed changes.

Create a clean final document that outlines the protocol. Distribute the
document to the staff, or to the particular people whom it affects. Follow up
with the employees to make sure that the instructions are understandable.

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 Self- Check 6.1-2
True or False: read each sentence below then wright TRUE if the statement
is correct hen False if it is not.

1. Protocols and procedures are the specific way that a policy, rule or
principle is carried out.
2. Procedures can help small businesses to function productively by
ensuring that everyone executes tasks in the same way.
3. Procedures can not be beneficial for organizations to review their
protocols and procedures on an annual basis to ensure that they are
up to date and reflect current business objectives.
4. The last step in making a protocol is to identify the policy or rule that
needs a procedure attached to it.
5. Document the procedure in a step-by-step format

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 Answer Key 6.1-2

1. True
2. True
3. False
4. False
5. True

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 INFORMATION SHEET 6.1-3
Confidentiality

Learning Objectives: After reading this INFORMATION SHEET, you MUST

be able to:

1. Described the importance of maintaining confidentiality about

information’s
2. Know the importance of maintaining confidentiality.

Data confidentiality is about protecting data against unintentional,

unlawful, or unauthorized access, disclosure, or theft.

Confidentiality has to do with the privacy of information, including

authorizations to view, share, and use it. Information with low
confidentiality concerns may be considered "public" or otherwise not
threatening if exposed beyond its intended audience. Information with high
confidentiality concerns is considered secret and must be kept confidential
to prevent identity theft, compromise of accounts and systems, legal or
reputational damage, and other severe consequences.

Examples of data with high confidentiality concerns include:

 Social Security numbers, which must remain confidential to prevent

identity theft.
 passwords, which must remain confidential to protect systems and
accounts.

Consider the following when managing data confidentiality:

 To whom data can be disclosed

 Whether laws, regulations, or contracts require data to remain
confidential
 Whether data may only be used or released under certain conditions
 Whether data is sensitive by nature and would have a negative impact if
disclosed

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 Whether data would be valuable to those who aren't permitted to have it
(e.g., hackers)

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Confidentiality

Confidentiality is the protection of personal information. Confidentiality

means keeping a client’s information between you and the client, and not
telling others including co-workers, friends, family, etc.
Examples of maintaining confidentiality include:
 individual files are locked and secured

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  support workers do not tell other people what is in a client’s file
unless they have permission from the client
 information about clients is not told to people who do not need to
know
 clients’ medical details are not discussed without their consent
 adult clients have the right to keep any information about
themselves confidential, which includes that information being
kept from family and friends.
The types of information that is considered confidential can include:
 name, date of birth, age, sex and address
 current contact details of family, guardian etc
 bank details
 medical history or records
 personal care issues
 service records and file progress notes
 individual personal plans
 assessments or reports
 guardianship orders
 incoming or outgoing personal correspondence.
Other information relating to ethic or racial origin, political opinions,
religious or philosophical beliefs, health or sexual lifestyle should also be
considered confidential.
Adult clients have the right to determine what information they consider
personal and confidential.
There is, however, no such thing as absolute confidentiality in the
community services industry. Workers are required to keep notes on all
interactions with clients and often to keep statistics about who is seen and
what issues are addressed. As a worker, there will be times when you could
be faced with some personal difficulties regarding confidentiality. You need
to give your client an assurance that what is said will be in confidence (that
it will stay secret between you and the client) because, unless you are able
to do that, the client is unlikely to be open with you. However, you also need
to be aware of the limits to the confidentiality that you are offering. There
are several instances where total confidentiality is either impossible,
undesirable or illegal. These include:
 cases where the law requires disclosure of information which will
be
o if the health and/or welfare of a child or young person
is at risk. You are required to contact Department of
Community Services and notify them of your
concerns.
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 o if your client tells you he/she has committed a serious
crime. You are required to notify your supervisor or
the police directly.
o if a worker is subpoenaed to present information in a
court of law
 when the client needs to be protected from harming themself (eg if
suicidal)
 where others may need to be protected (if the client has
threatened to harm others or will do so inadvertently)
 the need to keep records
 when working in conjunction with other professionals in caring
for a client
 the requirements of professional supervision, training, workshops
or seminars.
 For more details go to the sections on Legislation governing
confidentiality and Exceptions to the general rule of
confidentiality.
It is always good practice to tell clients at the beginning of your contact with
them that whatever they tell you is confidential except in the above
circumstances.
When writing up case notes you need to be careful about what you include
and how you write this information up. Always remember that clients have
the right to see files and read anything that has been written about them.
When working with other professionals it is good practice to obtain the
written consent of the client before exchanging information.
If you are going to be discussing a client and their situation in supervision,
in a training session or at a workshop, you can always change the name and
any information that may identify the client. Other workers in these
situations are also bound by the same ethical and legal requirements
relating to confidentiality that you are.
Confidentiality also extends to things like:
 names and addresses of clients
 phone numbers and addresses of staff and volunteers
 names and personal details of people who donate money or time
 details of funding agreements
 information about strategic planning.

Importance of confidentiality
Confidentiality is important for several reasons. One of the most important
elements of confidentiality is that it helps to build and develop trust. It
potentially allows for the free flow of information between the client and
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worker and acknowledges that a client’s personal life and all the issues and
problems that they have belong to them.
One of the major purposes for obtaining a client’s consent before speaking to
a third party (such as another agency or a family member/carer) is to
protect the confidentiality and privacy of the client. Informed consent
(obtaining personal information with the formal permission of the client or a
person who has the legal authority to provide permission on behalf of the
client) is considered essential in maintaining the privacy of the client.
It is important to keep your clients’ business as just that – their business.
You should only discuss matters relating to your clients’ business with co-
workers, and then only what needs to be discussed. Discussions should
take place in the workplace and not be audible to other members of staff or
the general public. You should never discuss clients’ business with family or
friends.
Respect for client confidentiality and staff personal information should be a
high priority for all community services to comply with legislation that
governs disclosure of information. In this regard all organisations need to
have policies and procedures that provide guidelines for workers.
Appropriate worker behaviour can also be incorporated in a code of conduct.
To ensure confidentiality, workers should only access confidential
information for work that is covered by their job description and the policies
and procedures of the organisation. They should only disclose information to
other parties where a client (or co-worker in relation to their personal
information) has consented to the release of the information or where
disclosure is required or mandated by legislation due to indications of risk of
harm. Further workers need to ensure that any information that is collected
is securely stored and disposed of.

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 Self-Check 6.1-3

Enumeration: List some examples of data that needs to be kept confidential

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 Answer Key 6.1-3

1. Social security number

2. Passwords
3. name, date of birth, age, sex and address
4. current contact details of family, guardian etc

5. bank details
6. medical history or records
7. personal care issues
8. service records and file progress notes
9. individual personal plans
10. assessments or reports
11. guardianship orders
12. incoming or outgoing personal correspondence.

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 INFORMATION SHEET 6.1-4
Accuracy

Learning Objectives: After reading this INFORMATION SHEET, you MUST

be able to:

1. Described the importance of maintaining accurate information

2. Know the importance of maintaining accuracy.

Accuracy is to be ensuring that the information is correct and without any

mistake. Information accuracy is important because may the life of people
depend in it like the medical information at the hospitals, so the information
must be accurate.

The quality of information measured by accuracy, timeliness, completeness,

relevance and if it is easy to understood by the users, so the accuracy
important for quality of information. And the accuracy represents all
organization actions. To get accurate information we need the right value.

If someone gave inaccurate information, it is difficult to find who made the

mistake. There are many reasons for inaccurate information. The most
common case is when the user enter wrong value. Also inaccurate
information may accrue by typographical mistake. To avoid this mistakes
the organization must find who has experience and skills for data entry and
it must use the programs which discover the typographical mistake.

Inaccurate information with the passage of time it be hard to avoided if no

one update it( like the address, phone numbers)and the information going to
be more inaccurate.

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The importance of data accuracy cannot be contained in words as it is one of

the most important components of data quality. It alludes to whether the

data values saved for a particular object, product, or service are accurate.

Any data you provide must be accurate, as this is what gives your business

credibility. These data values must be accurate and provided in an

unambiguous and consistent form.

When it comes to data accuracy, there are two most important

characteristics: content and form. The form is especially important, as it’s

needed to eliminate any possible ambiguities about the content.

Creating data values requires some discipline and absolute precision to make

sure all data values are accurate. Let’s delve deeper into why data accuracy

matters for your business and how it can contribute to growing your

profitability.

Data Accuracy Improves Your Decision-Making Process

Since information is essential in online business, accurate and reliable data

is an essential tool you can use to base your decisions on. This is how you’ll

make the right moves and beat your competition.

This strategy brings some great benefits along the way:

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 Increased revenue — cleansed and accurate data is a reliable and

effective way to make the right decisions and drive sales.

 Reduced costs — accurate and updated data helps you save money that

would otherwise be spent on ineffective decisions, strategies, and tactics.

 Improved customer experience and increased customer

satisfaction — customers appreciate any business with accurate data.

More importantly, current and accurate data about your consumers and

their buying and online habits help your marketing efforts by making

sure your messages reach the right audience.

With the right timing, this helps you engage with the customers in a

personalized way and encourage them to come full circle in their customer

journey.

 Time-saving — if you manage your data the right way, you reduce costs

and save time since you will not have to spend time rectifying your

mistakes and errors.

 Improved ROI — data accuracy demands data assets, and these assets

are nothing more than an investment. The more accurate your data is,

the greater the return on investment, and there are no additional costs.

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Five Reasons Why Data Accuracy is so Important to Businesses

Getting data management right is the only safe way of adopting the latest,

most advanced technologies, and getting ahead of the competition.

The more businesses use modern technology, the more data they generate.

All that data growth is nothing more than a lucrative opportunity you can

exploit to increase your profitability.

Since data is so essential, data accuracy becomes crucial for your business

success. The higher the quality, the bigger the chance there is to prosper.

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Here are five great reasons why high-quality data greatly matters to your

business.

1. Data Accuracy Enables Better Decision Making

The highest data quality provides a certain level of confidence to all who

depend on that data. If data quality is high, the users will be able to produce

better outputs.

This increases business efficiency and lowers risk in the outcomes. With

reliable outputs, businesses can improve their entire decision-making

process and easily mitigate any risks along the way.

2. Improved Productivity

The importance of data accuracy goes far beyond just decision-making. It’s

directly related to productivity.

Accurate data makes the job of your employees much easier. Instead of

wasting time on finding and fixing data errors, your staff can shift their focus

on more important tasks and goals.

3. Data Accuracy Leads to Lower Cost

Data errors are extremely costly for any business, but the risk is far greater

than just losing money. Aside from exhausting your financial resources, poor

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data quality will negatively reflect on your brand credibility, productivity, and

efficiency.

In the worst-case scenario, your brand reputation will be ruined, and you’ll

lose most of your customers. The biggest problem with poor data is that one

mistake causes other mistakes, and it takes a tremendous amount of time to

identify and fix these errors.

Instead of using your freshly gathered data to generate business strategies,

you’ll have to spend that time fixing errors, which is a costly task.

Poor data also results in the inability to cope with the latest marketing

trends, missing great business opportunities. Losing track of such trends

gives your competitors an advantage over you.

4. Improved Marketing

Nothing matters more than data accuracy for your marketing efforts and that
is why the importance of data accuracy cannot be undermined. High-quality

data allows you to market to the right audience, which reduces both time

and cost.

In return, sending the right message to the right audience means improving

your marketing and increasing sales.

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Target marketing gives real results and helps you grow your business, but

more importantly, it allows you to keep your customers engaged with your

brand.

5. Aids in Compliance

Following various regulations is of the utmost importance for any business,

as this directly impacts your relationship with customers.

Therefore, maintaining the highest quality data makes a huge difference

between paying extremely expensive fines and compliance. Regulations keep

evolving, and your business needs to evolve with them. The only way to do

that is by maintaining data accuracy.

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 Self-Check 6.1-4
Identification: Read each sentence and identify what is being asked or
described.

1. Cleansed and accurate data is a reliable and effective way to

make the right decisions and drive sales.

2. Accurate and updated data helps you save money that would

otherwise be spent on ineffective decisions, strategies, and

tactics.

3. Customers appreciate any business with accurate data. More

importantly, current and accurate data about your consumers

and their buying and online habits help your marketing efforts

by making sure your messages reach the right audience.

4. If you manage your data the right way, you reduce costs and

save time since you will not have to spend time rectifying your

mistakes and errors.

5. Data accuracy demands data assets, and these assets are

nothing more than an investment. The more accurate your data

is, the greater the return on investment, and there are no

additional costs.

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 Answer Key 6.1-4

1. Increased revenue

2. Reduced costs

3. Improved customer experience and increased customer satisfaction

4. Time-saving

5. Improved ROI

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 INFORMATION SHEET 6.1-5
Data Analysis Techniques/Procedures

Learning Objectives: After reading this INFORMATION SHEET, you MUST

be able to:

1. Identify the different data analysis techniques

2. Identify the different data analysis procedures.

What is Data Analysis? Definition & Example

The systematic application of statistical and logical techniques to describe
the data scope, modularize the data structure, condense the data
representation, illustrate via images, tables, and graphs, and evaluate
statistical inclinations, probability data, to derive meaningful conclusions, is
known as Data Analysis. These analytical procedures enable us to induce
the underlying inference from data by eliminating the unnecessary chaos
created by the rest of it. The generation of data is a continual process; this
makes data analysis a continuous, iterative process where the collection and
performing data analysis simultaneously. Ensuring data integrity is one of
the essential components of data analysis.
There are various examples where data analysis is used ranging from
transportation, risk and fraud detection, customer interaction, city planning
healthcare, web search, digital advertisement, and more.
Considering the example of healthcare as we have noticed recently that with
the outbreak of the pandemic Coronavirus hospitals are facing the challenge
of coping up with the pressure in treating as many patients as possible,
considering data analysis allows to monitor machine and data usage in such
scenarios to achieve efficiency gain.
Before diving any more in-depth, make the following pre-requisites for
proper Data Analysis:

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  Ensure availability of the necessary analytical skills
 Ensure appropriate implementation of data collection methods and
analysis.
 Determine the statistical significance
 Check for inappropriate analysis
 Ensure the presence of legitimate and unbiased inference
 Ensure the reliability and validity of data, data sources, data analysis
methods, and inferences derived.
 Account for the extent of analysis

Data Analysis Methods

There are two main methods of Data Analysis:

1. Qualitative Analysis
This approach mainly answers questions such as ‘why,’ ‘what’ or ‘how.’ Each
of these questions is addressed via quantitative techniques such as
questionnaires, attitude scaling, standard outcomes, and more. Such kind
of analysis is usually in the form of texts and narratives, which might also
include audio and video representations.

2. Quantitative Analysis
Generally, this analysis is measured in terms of numbers. The data here
present themselves in terms of measurement scales and extend themselves
for more statistical manipulation.
The other techniques include:

3. Text analysis
Text analysis is a technique to analyze texts to extract machine-readable
facts. It aims to create structured data out of free and unstructured content.
The process consists of slicing and dicing heaps of unstructured,
heterogeneous files into easy-to-read, manage and interpret data pieces. It is
also known as text mining, text analytics, and information extraction.
The ambiguity of human languages is the biggest challenge of text analysis.
For example, the humans know that “Red Sox Tames Bull” refers to a
baseball match, but if this text is fed to a computer without background
knowledge, then it would generate several linguistically valid interpretations,
and sometimes people not interested in baseball might have trouble
understanding it too.

4. Statistical analysis

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Statistics involves data collection, interpretation, and validation. Statistical
analysis is the technique of performing several statistical operations to
quantify the data and apply statistical analysis. Quantitative data involves
descriptive data like surveys and observational data. It is also called a
descriptive analysis. It includes various tools to perform statistical data
analysis such as SAS (Statistical Analysis System), SPSS (Statistical
Package for the Social Sciences), Stat soft, and more.

5. Diagnostic analysis
The diagnostic analysis is a step further to statistical analysis to provide
more in-depth analysis to answer the questions. It is also referred to as root
cause analysis as it includes processes like data discovery, mining and drill
down and drill through.
The diagnostic analysis is a step further to statistical analysis to provide
more in-depth analysis to answer the questions. It is also referred to as root
cause analysis as it includes processes like data discovery, mining and drill
down and drill through.
The functions of diagnostic analytics fall into three categories:

 Identify anomalies: After performing statistical analysis, analysts are

required to identify areas requiring further study as such data raise
questions that cannot be answered by looking at the data.
 Drill into the Analytics (discovery): Identification of the data
sources helps analysts explain the anomalies. This step often requires
analysts to look for patterns outside the existing data sets and
requires pulling in data from external sources, thus identifying
correlations and determining if any of them are causal in nature.
 Determine Causal Relationships: Hidden relationships are
uncovered by looking at events that might have resulted in the
identified anomalies. Probability theory, regression analysis, filtering,
and time-series data analytics can all be useful for uncovering hidden
stories in the data.

6. Predictive analysis
Predictive analysis uses historical data and feds it into the machine learning
model to find critical patterns and trends. The model is applied to the
current data to predict what would happen next. Many organizations prefer
it because of its various advantages like volume and type of data, faster and
cheaper computers, easy-to-use software, tighter economic conditions, and a
need for competitive differentiation.
The following are the common uses of predictive analysis:
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  Fraud Detection: Multiple analytics methods improves pattern
detection and prevents criminal behavior.
 Optimizing Marketing Campaigns: Predictive models help
businesses attract, retain, and grow their most profitable customers.
It also helps in determining customer responses or purchases,
promoting cross-sell opportunities.
 Improving Operations: The use of predictive models also involves
forecasting inventory and managing resources. For example, airlines
use predictive models to set ticket prices.
 Reducing Risk: Credit score that is used to assess a buyer’s
likelihood of default for purchases is generated by a predictive model
that incorporates all data relevant to a person’s creditworthiness.
Other risk-related uses include insurance claims and collections.

7. Prescriptive Analysis
Prescriptive analytics suggests various courses of action and outlines what
the potential implications could be reached after predictive analysis.
Prescriptive analysis generating automated decisions or recommendations
requires specific and unique algorithmic and clear direction from those
utilizing the analytical techniques.

Data Analysis Process

Once you set out to collect data for analysis, you are overwhelmed by the
amount of information that you find to make a clear, concise decision. With
so much data to handle, you need to identify relevant data for your analysis
to derive an accurate conclusion and make informed decisions. The
following simple steps help you identify and sort out your data for analysis.

1. Data Requirement Specification - define your scope:

o Define short and straightforward questions, the answers to

which you finally need to make a decision.
o Define measurement parameters
o Define which parameter you take into account and which one
you are willing to negotiate.
o Define your unit of measurement. Ex – Time, Currency, Salary,
and more.

2. Data Collection

o Gather your data based on your measurement parameters.

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 o Collect data from databases, websites, and many other sources.
This data may not be structured or uniform, which takes us to
the next step.

3. Data Processing

o Organize your data and make sure to add side notes, if any.
o Cross-check data with reliable sources.
o Convert the data as per the scale of measurement you have
defined earlier.
o Exclude irrelevant data.

4. Data Analysis

o Once you have collected your data, perform sorting, plotting,

and identifying correlations.
o As you manipulate and organize your data, you may need to
traverse your steps again from the beginning, where you may
need to modify your question, redefine parameters, and
reorganize your data.
o Make use of the different tools available for data analysis.

5. Infer and Interpret Results

o Review if the result answers your initial questions

o Review if you have considered all parameters for making the
decision
o Review if there is any hindering factor for implementing the
decision.
o Choose data visualization techniques to communicate the
message better. These visualization techniques may be charts,
graphs, color coding, and more.

Once you have an inference, always remember it is only a hypothesis. Real-

life scenarios may always interfere with your results. In the process of Data
Analysis, there are a few related terminologies that identity with different
phases of the process.
1. Data Mining
This process involves methods in finding patterns in the data sample.
2. Data Modelling
This refers to how an organization organizes and manages its data.

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Data Analysis Techniques
There are different techniques for Data Analysis depending upon the
question at hand, the type of data, and the amount of data gathered. Each
focuses on strategies of taking onto the new data, mining insights, and
drilling down into the information to transform facts and figures into
decision making parameters. Accordingly, the different techniques of data
analysis can be categorized as follows:

1. Techniques based on Mathematics and Statistics

 Descriptive Analysis: Descriptive Analysis takes into account the

historical data, Key Performance Indicators, and describes the
performance based on a chosen benchmark. It takes into account past
trends and how they might influence future performance.
 Dispersion Analysis: Dispersion in the area onto which a data set is
spread. This technique allows data analysts to determine the
variability of the factors under study.
 Regression Analysis: This technique works by modeling the
relationship between a dependent variable and one or more
independent variables. A regression model can be linear, multiple,
logistic, ridge, non-linear, life data, and more.
 Factor Analysis: This technique helps to determine if there exists any
relationship between a set of variables. In this process, it reveals other
factors or variables that describe the patterns in the relationship
among the original variables. Factor Analysis leaps forward into useful
clustering and classification procedures.
 Discriminant Analysis: It is a classification technique in data mining.
It identifies the different points on different groups based on variable
measurements. In simple terms, it identifies what makes two groups
different from one another; this helps to identify new items.
 Time Series Analysis: In this kind of analysis, measurements are
spanned across time, which gives us a collection of organized data
known as time-series.

2. Techniques based on Artificial Intelligence and Machine Learning

 Artificial Neural Networks: a Neural network is a biologically-

inspired programming paradigm that presents a brain metaphor for
processing information. An Artificial Neural Network is a system that
changes its structure based on information that flows through the
network. ANN can accept noisy data and are highly accurate. They
can be considered highly dependable in business classification and
forecasting applications.

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  Decision Trees: As the name stands, it is a tree-shaped model that
represents a classification or regression models. It divides a data set
in smaller subsets simultaneously developing into a related decision
tree.
 Evolutionary Programming: This technique combines the different
types of data analysis using evolutionary algorithms. It is a domain-
independent technique, which can explore ample search space and
manages attribute interaction very efficiently.
 Fuzzy Logic: It is a data analysis technique based on probability
which helps in handling the uncertainties in data mining techniques.

3. Techniques based on Visualization and Graphs

 Column Chart, Bar Chart: Both these charts are used to present
numerical differences between categories. The column chart takes to
the height of the columns to reflect the differences. Axes interchange
in the case of the bar chart.
 Line Chart: This chart is used to represent the change of data over a
continuous interval of time.
 Area Chart: This concept is based on the line chart. It additionally
fills the area between the polyline and the axis with color, thus
representing better trend information.
 Pie Chart: It is used to represent the proportion of different
classifications. It is only suitable for only one series of data. However,
it can be made multi-layered to represent the proportion of data in
different categories.
 Funnel Chart: This chart represents the proportion of each stage and
reflects the size of each module. It helps in comparing rankings.
 Word Cloud Chart: It is a visual representation of text data. It
requires a large amount of data, and the degree of discrimination
needs to be high for users to perceive the most prominent one. It is
not a very accurate analytical technique.
 Gantt Chart: It shows the actual timing and the progress of activity in
comparison to the requirements.
 Radar Chart: It is used to compare multiple quantized charts. It
represents which variables in the data have higher values and which
have lower values. A radar chart is used for comparing classification
and series along with proportional representation.
 Scatter Plot: It shows the distribution of variables in the form of
points over a rectangular coordinate system. The distribution in the
data points can reveal the correlation between the variables.
 Bubble Chart: It is a variation of the scatter plot. Here, in addition to
the x and y coordinates, the area of the bubble represents the 3rd
value.
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  Gauge: It is a kind of materialized chart. Here the scale represents the
metric, and the pointer represents the dimension. It is a suitable
technique to represent interval comparisons.
 Frame Diagram: It is a visual representation of a hierarchy in the
form of an inverted tree structure.
 Rectangular Tree Diagram: This technique is used to represent
hierarchical relationships but at the same level. It makes efficient use
of space and represents the proportion represented by each
rectangular area.
 Map
o Regional Map: It uses color to represent value distribution over
a map partition.
o Point Map: It represents the geographical distribution of data in
the form of points on a geographical background. When the
points are the same in size, it becomes meaningless for single
data, but if the points are as a bubble, then it additionally
represents the size of the data in each region.
o Flow Map: It represents the relationship between an inflow area
and an outflow area. It represents a line connecting the
geometric centers of gravity of the spatial elements. The use of
dynamic flow lines helps reduce visual clutter.
o Heat Map: This represents the weight of each point in a
geographic area. The color here represents the density.

Data Analysis Tools

There are several data analysis tools available in the market, each with its
own set of functions. The selection of tools should always be based on the
type of analysis performed, and the type of data worked. Here is a list of a
few compelling tools for Data Analysis.

1. Excel
It has a variety of compelling features, and with additional plugins installed,
it can handle a massive amount of data. So, if you have data that does not
come near the significant data margin, then Excel can be a very versatile
tool for data analysis.

2. Tableau
It falls under the BI Tool category, made for the sole purpose of data
analysis. The essence of Tableau is the Pivot Table and Pivot Chart and
works towards representing data in the most user-friendly way. It
additionally has a data cleaning feature along with brilliant analytical
functions.

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3. Power BI
It initially started as a plugin for Excel, but later on, detached from it to
develop in one of the most data analytics tools. It comes in three versions:
Free, Pro, and Premium. Its PowerPivot and DAX language can implement
sophisticated advanced analytics similar to writing Excel formulas.

4. Fine Report
Fine Report comes with a straightforward drag and drops operation, which
helps to design various styles of reports and build a data decision analysis
system. It can directly connect to all kinds of databases, and its format is
similar to that of Excel. Additionally, it also provides a variety of dashboard
templates and several self-developed visual plug-in libraries.

5. R & Python
These are programming languages which are very powerful and flexible. R is
best at statistical analysis, such as normal distribution, cluster
classification algorithms, and regression analysis. It also performs individual
predictive analysis like customer behavior, his spend, items preferred by
him based on his browsing history, and more. It also involves concepts of
machine learning and artificial intelligence.

6. SAS
It is a programming language for data analytics and data manipulation,
which can easily access data from any source. SAS has introduced a broad
set of customer profiling products for web, social media, and marketing
analytics. It can predict their behaviors, manage, and optimize
communications.

Conclusion
This is a complete beginner guide about What is Data Analysis? Data
Analysis is the key to any business, whether it be starting up a new venture,
making marketing decisions, continuing with a particular course of action,
or going for a complete shut-down. The inferences and the statistical
probabilities calculated from data analysis help to base the most critical
decisions by ruling out all human bias. Different analytical tools have
overlapping functions and different limitations, but they are also
complementary tools. Before choosing a data analytical tool, it is essential to
take into account the scope of work, infrastructure limitations, economic
feasibility, and the final report to be prepared.

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 Self-Check 6.1-5
Identification: Read each sentence below then identify what is being
described or define.
1. Both these charts are used to present numerical differences
between categories.
2. This chart is used to represent the change of data over a
continuous interval of time.
3. This concept is based on the line chart. It additionally fills the
area between the polyline and the axis with color, thus
representing better trend information.
4. It is used to represent the proportion of different
classifications. It is only suitable for only one series of data
5. This chart represents the proportion of each stage and reflects
the size of each module.
6. It is a visual representation of text data. It requires a large
amount of data, and the degree of discrimination needs to be
high for users to perceive the most prominent one.
7. It shows the actual timing and the progress of activity in
comparison to the requirements.
8. It is used to compare multiple quantized charts. It represents
which variables in the data have higher values and which
have lower values.
9. It shows the distribution of variables in the form of points
over a rectangular coordinate system. The distribution in the
data points can reveal the correlation between the variables.
10. It is a variation of the scatter plot. Here, in addition to the x
and y coordinates, the area of the bubble represents the 3rd
value.

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 Answer Key 6.1-5

1. Column Chart, Bar Chart

2. Line Chart
3. Area Chart
4. Pie Chart
5. Funnel Chart
6. Word Cloud Chart
7. Gantt Chart
8. Radar Chart
9. Scatter Plot
10. Bubble Chart

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 INFORMATION SHEET 6.1-6
Reporting Requirements to Range of Audiences

Learning Objectives: After reading this INFORMATION SHEET, you MUST

be able to:

1. Identify the different requirements when making a report for different

types of audience.

A document should never have more than one audience; that is, the only
audience a document should have is the group of people the document is
intended for. Good technical writing has to focus on its audience's needs. an
audience is a group of people with similar needs and similar levels of
technical and subject matter expertise and who will be using the document.

start by identifying my audience's needs and ask myself the following

questions before I begin writing:

Who will use this document?

How will each audience use this document?
What information does each audience need in this document for them to use
it?

During this discussion, I will use the requirements document as my primary

example of how these concepts apply.

Who Will Use This Document?

Contrary to popular opinion, the first question you must ask yourself is not
"What is the purpose of this document?" The first thing you must ask
yourself is "Who will use this document?" The people who use a given
document often span different roles in the organization. These roles can be
departmental managers, developers, production line staff, etc. These roles in
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the organization have corresponding roles in each project, such as:
management, project team member, and end user. Each of the roles can be
considered a different audience because the people in each role have
different levels of technical knowledge, subject matter knowledge, and uses
for the document. To identify your audience, you, the writer, must ask
yourself these types of questions:

Whose job tasks are defined by this document?

Who needs to review or approve this document?
Who uses this document in presentations?
Who is responsible for ensuring that project documentation meets your
company's standards?

These people comprise your audience. In the case of the requirements

document, the answers can be the project team, departmental management,
subject matter experts (SME), and, especially in regulatory environments,
quality auditors. Some organizations may have additional audiences, others
may have fewer. The project team's job tasks are defined by the
requirements document. As a result, the project team will design, develop,
and test the system based on what the requirements document indicates the
system should do.

Both the departmental management and subject matter experts (SMEs)

review and/or approve the requirements document. Often the managers will
use the document in presentations to senior staff and to other departments
(such as internal customers or sales/marketing staff), while SMEs make
presentations to users who are interested in how the system will meet their
needs.

Finally, the auditors will review the requirements document to ensure the
requirements document meets the company's standards for requirements
documents (e.g., the requirements document contains all the information
about each requirement the company wants) and to ensure the system does
what the project team claims it does.

How Will Each Audience Use This Document?

The next obvious question is "What does the audience need in this
document to use it?" To answer this question, you must ask yourself "How
will each audience use this document?" The meta-purpose of your document
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is determined when you decide which document you are writing.
Requirements documents have a different meta-purpose than a project plan;
the requirements document describes the system functions and features,
while the project plan explains the teams' approach and schedule for
developing the software.

In the end, each audience determines exactly how they will use your
document. The project team uses the requirements document to tell them
what the system should do (the classic idea of a requirements document'
purpose). In addition, the requirements document often serves as the
linchpin for other documents, such as the design document, testing
documentation, and configuration management documentation.

In addition to reviewing/approving the requirements for a system built in

their department, departmental managers use the requirements document
to gain support for the system. Therefore, the managers must be able to
demonstrate the value of the system to its users. This value helps justify the
expense of associated with the man-hours spent developing the system, the
cost of new hardware or software, and explains to the customer why they
should use the new system. In many ways, explaining to the customer why
they should use the new system can be the most important support, for
without customer buy-in, the system, no matter how well developed, is
doomed to fail through lack of user acceptance.

The SMEs use the requirements document very differently than either the
project team or the departmental management. While the SME does provide
information about what the user needs, they also use the requirements
document to tell the user how the software will meet their needs. In this
way, the SME solicits feedback regarding the system and gains the user's
buy-in and thus provide an informal, if not a formal, review/approval of
system requirements documents to ensure they are complete.

Finally, the quality auditors use the requirements document to determine

what the system does. Then, with the requirements as a starting point, the
quality auditors will ensure that the design encompasses all the
requirements, that all requirements are accounted for in the testing, and
that the testing proves the code does what is required.

What Information Does Each Audience Need in This Document for

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Them to Use It?
Now you can ask yourself "What information does each audience in this
document to use it?" The document must provide sufficient information for
the audience to use it. Therefore, you must determine what knowledge each
audience has and what additional information each audience needs in the
document. When working on software systems, we need to determine what
our audiences know in terms of technological knowledge and subject matter
knowledge.

The project team should have a high level of technical knowledge; otherwise,
they would not be creating the system. However, the team may not have
much knowledge of the subject matter area. Therefore, we must include
enough explanation, either in the requirement or in an introduction, to
ensure that the project team will understand how their system is expected to
perform the functions specified in the requirements. If the requirements
specify that the system should perform date searches, describing the valid
date range, the type of input, and what records to search will make the
requirement more easily designed and tested.

Departmental managers have some technological knowledge because they

are managers in an IT department, but we can not expect them to have in-
depth knowledge of the newest changes in IT technology. However, they
usually will not have much knowledge of the subject matter area. As a
result, we must provide enough description of the subject matter and
enough explanation of the technological decisions to enable the managers to
evaluate and approve the solution and to enable them to discuss the value
of the system to senior staff and managers outside the department.

The SMEs have an in-depth knowledge of the subject, but have a limited
understanding of the computer technology to be used in the system.
Therefore, we must include a description and discussion of the technological
information so the SMEs will be able to evaluate and approve the solution
proposed and so they will be able to explain to the end users that the system
will meet their needs (and ideally be an improvement over their current
solution, if one exists). Many times all that is needed is reducing the amount
of "techie" jargon that is used and increasing the amount of "plain English."

If the requirements specify that the system should perform keyword

searches on the load field, stating that the system will search within the
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load field for a word or a phrase will make the requirement more easily
understood and applied by the SME. The quality auditors have a limited
understanding of both the computer technology to be used in the system
and of the subject matter. So, sufficient detail of both the computer
technology to be used in the system and the subject matter will have to be
included for the auditors to evaluate the efficacy of the requirements
document.

Because the key to writing good technical documentation is meeting your

audience's needs, returning to these questions on each revision of the
document ensures that the document continues to remain relevant to the
project.

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 Self-Check 6.1-6
True or False: read each sentence below then write True if the statement is
correct then False if it is incorrect.

1. A document should never have more than one audience; that is,
the only audience a document should have is the group of
people the document is intended for.
2. Contrary to popular opinion, the first question you must ask
yourself is not "What is the purpose of this document?"
3. The last question is "What does the audience need in this
document to use it?"
4. Now you can ask yourself "What information does each
audience in this document to use it?" The document must
provide sufficient information for the audience to use it.
5. the key to writing good technical documentation is meeting your
audience's needs, returning to these questions on each revision
of the document ensures that the document continues to
remain relevant to the project.

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 Answer Key 6.1-6

1. true
2. true
3. false
4. true
5. true

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