FOCUS CHARTING

WRH uses the Focus Charting documentation system. With this system of documentation, the
nurse identifies a focus based on client concerns or behaviors determined during the
assessment.
At WRH, there are many potential points of assessment at which time the nurse might identify a
focus, including:
< Admission history, i.e. clinical data base
< Initial Head to Toe Assessment
< Ongoing Head to Toe Assessments
< Focused Assessments
A focus may reflect:
< A current client concern or behavior, such as decreased urinary output
< A change in clients condition or behavior, such as disorientation to time, place and
person.
< A significant event in the clients treatment, such as return from surgery.
When a focus is identified by the nurse, it is to be placed on the Focus List and included in
the front of the progress note section.
In this system, the assessment of the client and the care provided are organized under the headings
of data, action and response.
Data: Subjective and/or objective information that supports the stated focus or describe
nursing observations at the time of a significant event in treatment.
Action: Immediate or future nursing actions based on the nurses assessment/evaluation of
the clients condition.
Response: Description of client responses to both medical and nursing care.
An example of focus charting is seen below.
You assessed your patient at 0745 and noted a respiratory rate of 24, a dry, tight cough, expiratory
wheezing to the upper lobes, and the patient complains of shortness of breath and chest tightness.
You administered an aerosol treatment at 0750. You reassessed your patient at 0810 and found a
respiratory rate of 20, no cough, and decreased wheezing to the upper lobes. The patient states
that they no longer have chest tightness and do not feel short of breath. You sit down to
document at 0815.
DATE
Aug. 12, 02

TIME
0815

SERVICE
Nursing

SOB
D: Patient assessed at 0745, noted to have a RR of 24, dry, tight cough,
expiratory wheezing to the upper lobes, and c/o SOB and chest
tightness. -----------------------------------------------------------------------------------A: Aerosol treatment given as ordered at 0750, see med record.--------------R: At 0810 patients RR 20, no cough noted, decreased wheezing to upper
lobes. The patient states that they no longer have chest tightness and do not
feel short of breath. ----------------------------------------------J. Brown, RN-----If you have any questions or concerns regarding Focus Charting or DAR format, please contact your Clinical
Practice Manager.
Reference: Nursing Documentation Standards (Revised 2002), College of Nurses of Ontario.