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Focus Charting

Focus Charting

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Published by Julie Ann Galicana

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Published by: Julie Ann Galicana on Jan 20, 2012
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07/09/2013

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Focus Charting

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Focus charting describes the patient¶s perspective and focuses on documenting the patient¶s current status, progress towards goals and response to interventions. Purpose:
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Focus charting brings the focus of care back to the patient and the patients¶ concerns. Instead of a problem list or list of nursing and medical diagnosis, a focus column is used that incorporates many aspects of patient and patient care.

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The focus might be patient strength, problem, or need. Topics that may appear in the focus column include patients¶ concerns and behaviors; therapies and responses; significant events such as teaching, consultation, monitoring, management of activities of daily living or assessment of functional health patterns. The narrative portion of focus charting includes Data, Action and Response (D A R). The principal advantage of focus charting is in the holistic emphasis on the patient and his/her priorities including ease in charting. Objectives:
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To improve concise entries that would not duplicate patient information already provided on flow sheet/ checklist. To improve time efficiency with documentation. To facilitate communication among all disciplines. To easily identify critical patient issues/ concerns in the progress notes.

General Guidelines:
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Focus charting must be Evident at least once every shift. Focus charting must be patient- oriented not nursing task- oriented. Indicate the date and time of entry on the first column. Separate the topic words from the body of notes:  Focus note written on the second column  Data, Action and Response on the third column. Document patient¶s status on admission, for every transfer to/from another unit or discharge. Document only patient¶s concern and / or plan of care e.g. health per shift, hence, general notes are allowed. Sign name (e.g. M. Aquino, RN) for every time entry. Follow the do¶s of documentation. For eight hours shift, use blue or black ink for morning and afternoon shift, red ink for night shift. For twelve hours shift, use blue or black ink for morning and red ink for night shift.

when (a) responsibility for patient care changes from one department to another (b) a significant treatment. Intervention took place. as necessary. and auscultation (IPPA. Transfusion RBC.  Data is the subjective and/or objective information supporting the stated focus or describing the observation at the time of a significant event. collection of information from the patient. PRN medication required. Pre-(specify procedure) assessment.  Action describes the nursing interventions (independent. Skin integrity. present or future. Self care  To identify an exception to the expected outcome . basic and perspective) past. Even if you are uncertain whether the sign or symptom is important. Discharge status.when the purpose of the note is to document a new sign or symptom or a new behavior which is the current focus of care. Nausea  To document a new finding .  Response describes the patient outcome/response to interventions or describes how the care plan goals have been attained. percussion.when there has been an event of new patient condition. Pre-transfer assessment.Specific Guidelines: y Begin with comprehensive assessment of the patient using inspection. Post-(specify procedure) assessment. Document the four elements of focus charting. . laboratory results and other health care providers. Seizure. Code blue.when the purpose of the notes is to evaluate progress toward the defined patient outcome from the plan of care. (These may be ³temporary foci´ which do not need to be incorporated on the plan of care because they can quickly be resolved. Examples: Wheezes left base. Examples: Admission.  To describe all specific patient/ family teaching . it is valuable to communicate the information to the health care team. palpation. wherein:  Focus identifies the content or purpose of the narrative entry and is separated from the body of the notes in order to promote easy data retrieval and communication. Establish a focus of care.)  To document an acute change in patient¶s condition . family. y y y y Focus note is necessary:  To describe a patient¶s problem/ focus/ concern from the care plan . Examples: Activity tolerance.  To document a significant event or unusual episode in patient care .this is in compliance with a standard of care. Begin thrombolytic therapy. Discharge planning. to be addressed in the Progress Notes. Examples: Respiratory distress.when the significant finding or an outcome is not expected (the exception).) Include in the assessment. existing health records (such as checklist/flow sheets.

watching TV. Information from all these categories (Data. Action statement contains only nursing interventions (basic. ACTION and RESPONSE D: ³Sumasakit ang dibdib ko. none of the information is extraneous (e. perspective. Dietitian: Instruct low fat diet. Action. Response only contain information related to the focus.when the patient¶s focus is the pathophysiology rather than patient¶s response to the problem. To document an activity or treatment that was not carried out . when the patient outcome is evident. and Response) should be used only as they are relevant or available. S: Lampe. Data. Action. Examples: Social service/ financial assistance.´ Midclavicular line pain of 4 on scale y y y y . y y Data statements contain objective and/or subjective information. This happens most frequently in highly technical areas such as critical care.´ S: Lampe. RN FOCUS Chest Pain DATA. Physical therapy/ crutch walking. RN 12:00 am Chest Pain R: resting in bed. SL. Response statements are documented after PRN medications are administered. Patient outcome are evident in the response statements.: asleep. ³nabawasan na sakit ng dibdib ko.when all members of the patient care team use on patient programs record.  To identify the discipline making the entry as well as the topic of the note . Examples of Focus Charting: DATE/TIME 03/08/08 10 am A: Medicated with Isordil 5mg.when treatment or activity in the flow sheet was not provided to the patient or was different from the standard of care. However all appropriate information should be included to ensure complete documentation:  DATA and ACTION are responded at one hour and RESPONSE is not added until later. independent) past. visited by family).  To best describe patient¶s condition in relation to medical diagnosis . present or future.g. Rating of 2.

gastrostomy bag at body level. vital signs stable. ACTION and RESPONSE R: Patient demonstrates he is able to change his Dressing own abdominal dressing Change using aseptic technique S: Lampe. ACTION and RESPONSE D: ³I feel like my stomach is filling up with pressure again and I¶m 10:00pm nauseated. RN y DATA is used when the purpose of the note is to document assessment finding and there is no flow sheet/ checklist for that purpose. Example: DATE/TIME 03/15/08 1 pm FOCUS Health Teaching: DATA. dressing on RLQ is clean and dry. awake and alert. Example: DATE/TIME 03/22/08 10:00 pm FOCUS Nausea DATA. . R: ³I feel like better now. RN y ACTION and RESPONSE are repeated without additional data to show the sequence of decision making based on evaluating patient response to the initial intervention.´ Abdomen round and soft.´ S: Lampe.y Response is used alone to indicate a care of plan goal has been accomplished. IV right forearm patent. ACTION and RESPONSE D: Received from the RR via stretcher. ³Minimal incisional pain at this time rating of 3.´ Approximately 200 cc golden fluid returned as much flatus. Example: DATE/TIME 03/18/09 2:20 pm FOCUS Post transfer assessment DATA. Rare bowel sounds. moving all extremities voluntarily. A: Gastrostomy bag lowered. Foley catheter in place with clear yellow urine.

R: Return demonstration of radial pulse. Document any discomfort. Monitor how long bag is tolerated at body level. RN http://www.net/davejaymanriquez/focus-charting-fdar . RN y Begin the note with ACTION when the patient¶s interaction begins with intervention or when including date would be unnecessary repetition. Lampe. Example: DATE/TIME 03/01/08 2:20 pm FOCUS Health Teaching digoxin DATA. Given information card. ACTION and RESPONSE A: Patient instructed on the actions and side effects of digoxin. ³I understand the purpose of medication. Patient instructed to call nurse when he is uncomfortable. Monitor abdominal status.´ S. R: ³I understand plan.slideshare.10:00 pm Nausea Nausea A: Keep gastrostomy bag at body level. Discusses when he would call the physician about the medicine.´ S Lampe.

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