Focus Charting in Pediatric ward MedSurgical

ROT: PEDIA - Prof. Orense CLINICAL

I. FOCUS CHARTING nursing process.

 When using NANDA labels for nursing diagnoses in
● Format for organizing information in the narrative portion of the the care plan, the two-part or three-part diagnosis is
patient record. written in the care plan or care path.
● Describes patient’s perspectives  Person who makes the care plan entry chooses the word
● Focuses on documenting patient’s current status, progress toward that best communicates the patient focus by underlining
goals, and response to interventions. or highlighting the “focus word” on the care plan.
● Patient centered rather than problem-oriented  The designated focus word or phrase is used in the
notes rather than the long NANDA statement to make
● Uses a column format to separate topic words or phrases from
daily charting quicker and easier.
the body of the notes  Ex.: self care, eating, skin integrity, activity
● Aids communication among members of the health care team tolerance
2. When facility has instituted a system of charting by
Date/Time Focus Progress Notes exception to identify an exception to the expected outcome.
04/14/09 Incisional Pain Data: Reports pain 3. To document a new finding
level of 6 out of 10  E.g. new sign/symptom, new behavior (temporary)
 Ex.: constipation, chest pain, disoriented
Action: Consult 4. When there is an acute change in the patient’s condition
with Dr. Santos new  Ex.: respiratory distress, seizure, code blue
order for Diclofenac 5. To document a significant event or unusual episode in
Na 1 amp IM STAT patient care not documented elsewhere. Identifying a
given. significant treatment/intervention took place.
Response: Reports  Ex.: to surgery, transfusion RBC, begin
chemotherapy
pain level of 1 on a
6. To emphasize if any activity or treatment has not been
scale of 10 after 30 carried out or is different from the standard of care. In
min. flowsheets with checklist, put an asterisk and write a focus
note describing the problem
R.Mendoza, R.N.  Ex.: in physiotherapy: dyspnea, loss of appetite
7. To document compliance with a standard care or with
hospital policy; easier for chart audits
Purposes  Ex.: return from surgery, transfer, discharge
● To analyze, synthesize, and collate the extensive collection of status
patient data from flowsheets into a summary statement which 8. To identify the discipline making the entry
highlights the caregiver’s clinical decision-making  Ex.: social service: discharge planning
● To highlight the major focus of patient concern, caregiver Nursing: ostomy teaching
Dietician: instruct low fat diet
intervention, and patient outcome to that intervention.
Physical therapy: crutch walking
9. When the patient’s condition and interventions can best be
II. FOUR ESSENTIAL ELEMENTS IN FOCUS described in relation to the medical diagnosis
CHARTING  Problem may be the pathophysiology rather than the
● Focus Column - identifies the content or purpose of the patient’s response to the problem
 Ex.: bigeminy (or other cardiac arrythmias)
narrative entry and is separated from the body of the notes in
hyperbilirubinemia
order to promote easy data retrieval and communication.
● Data - subjective and/or objective information supporting the
stated focus or describing the observations at the time of a Dont’S In Focus Charting
● Generic terms: ex. Status, summary
significant event.
� Ask yourself: “What is the focus of my care or
● Action - describes the intervention’s past, present, or future of
concern for this patient?”
the healthcare team member.
● Response - describes the patient outcome/response to
intervention or describes the care plan goals have been attained. Data
● Patient objective and subjective data base for the stated
Focus Column focus
● Gives you the current patient condition and provider concerns ● What do you see, hear, touch, smell
● Major advantage of focus charting
Action
● What actions did the nurse take as a response to the stated
focus? Did you initiate a standard of care? A treatment or
teaching protocol?

Response
● What happened to the patient as a result of the
action/intervention?
● What are the patient outcomes?
● Does the current status or behavior match the desired
9 USES OF THE FOCUS COLUMN
outcome?
1. When the purpose of the note is to evaluate progress toward
the defined patient outcome from the plan of care, USE: the
patient problem/focus/concern from the care plan - use of
same word provides visual link throughout the stages of the
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[NCM 112 CLINICAL] FOCUS CHARTING ON PEDIA – Pro. Orense

Disadvantage of Narrative Charting

● Subjectivity
● Client’s problem may be difficult to track
● Often fails to reflect the nursing process

IV. NARRATIVE REPORT

● is a method in which nursing intervention and the impact of
these interventions on client outcomes are recorded in
chronological order covering a specific time frame. Data is
recorded in the progress notes, often without an organizing
framework. Narrative charting may stand alone or it may be
complemented by other tools, such as flow sheets and
checklists.

Narrative charting
● Traditional method of nursing documentation
● Chronological account written in paragraphs describing
client’s status, interventions, treatments, and the client’s
response to treatments
● Most flexible

V. PROBLEM ORIENTED CHARTING

● Focuses on the client’s problem and employs a structured,
logical format

4 Critical Components:
1. Database (assessment data)
2. Problem List (client’s problems numbered according to
when identified)
3. Initial Plan (outline of goals, expected outcomes, learning
needs, and further data, if needed)
4. Progress notes (charting based on the SOAP, SOAPIE, or
SOAPIER format)

III. SOAP / SOAPIE(R) CHARTING

● is a problem-oriented approach to documentation whereby the
nurse identifies and lists client problems; documentation then
follows according to the identified problems.
● Documentation is generally organized according to the following
headings:
Subjective Data (e.g., how does the client feel?)
Objective Data (e.g., results of the physical exam, relevant
vital signs)
Assessment (e.g., what is the client’s status)
Plan (e.g., does the plan stay the same? Is a change
needed?)
Intervention (e.g., what occurred? What did the nurse do?)
Evaluation (e.g., what is the client outcome following the
intervention)
Revision (e.g., what changes are needed to the care plan)
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