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Focus Charting Is Intended To Make Client and Client Concerns and Strengths The Focus of Care. 3 Columns

Focus charting organizes client information into three columns: date/time, focus of care (e.g., condition, symptom), and progress notes using a DAR (data, action, response) structure. The focus can be a medical concern, nursing diagnosis, behavior, or strength. Progress notes provide holistic client data to guide the nursing process. An example chart documents a client's fever, hypotension, surgical wound, and decreased appetite over time with nursing assessments and interventions.

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Jan Federick Bantay
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297 views2 pages

Focus Charting Is Intended To Make Client and Client Concerns and Strengths The Focus of Care. 3 Columns

Focus charting organizes client information into three columns: date/time, focus of care (e.g., condition, symptom), and progress notes using a DAR (data, action, response) structure. The focus can be a medical concern, nursing diagnosis, behavior, or strength. Progress notes provide holistic client data to guide the nursing process. An example chart documents a client's fever, hypotension, surgical wound, and decreased appetite over time with nursing assessments and interventions.

Uploaded by

Jan Federick Bantay
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as DOCX, PDF, TXT or read online on Scribd

Focus charting is intended to make client and client concerns and strengths the focus of care.

3 columns
of recording are usually used, date and time, focus, and progress notes. The focus can be a condition,
nursing diagnosis, a behavior, a signs and symptoms, an acute change in the client’s condition or a client
strength.

The focus charting system provides a holistic perspective of the client and client’s need. It also provides
a nursing process framework for the progress notes. The progress notes are organized into (D) data, (A)
action and (R) response, referred to as DAR.

Date/Time Focus Progress notes

8/17/20 fever D: flushed skin


6:00 am Temp of 38.7 C
A: tepid sponge bath done
Encourage to increase fluid intake
6:45 am R: temp recheck 37.5 C

Hypotension D: BP 90/60, dizziness


A: Elevate the legs of the person by placing
Pillow below the feet or place on T position
Provide well ventilation
Promote client’s safety like place siderails up
R: patient verbalize loss of dizziness.
BP recheck 110/90 mmHg
Risk for infection related D: incision located at the lower left abdominal
To surgical incision Quadrant with dressing unchanged
A: wound dressing done
R: no swelling or bleeding noted in the incision
site
Decrease in appetite D: the patient verbalize wala ko gana magkaon,
body weakness noted
A: encourage the patient to eat fruits to
replenish his body
offer small, frequent feeding
give multivitamins 1 tablet OD as ordered
R: The patient is able to eat well
D
Drug calculation x volume
S

IV computations

Gtts/min = volume to be infuse x drop factor


Hours of infusion x 60 mins

Hours to run = volume to be infuse


ml/hr

ml/hr = volume to be infused


hours of infusion

ml/min = ml/hour
60 minutes

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