= Focus charting describes the patient's perspective and focuses on documenting the patient's current status, progress towards goals and response to Taran aauirelae“* Purpo ¢ 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.= The focus might be patient strength, problem, or need. Topics that May appear in the focus column indude patients’ concerns and behaviors; therapies and responses; significant events such as teaching, consultation, monitoring, manag ement 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.* To easily identify critical patient issues/ Cele) sle ian} aM Une Kole] K=O le * To facilitate communication among all disciplines. * To improve time efficiency with documentation. CK ial Icey mec lesen clegiscn tg t-]mn fell (clmnle)m duplicate patient information already provided on flowsheet/ checklist.¢ Focus charting must be Evident at least once one * 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 roo) Un= ¢ Sign name (e.g. M. Aquino, RN) for every time entry. = * Document only patient’s concern and / or plan of care e.g, health per shift, hence, general notes are allowed, = ¢ Document patient's status on admission, for every transfer to/from another unit or discharge.= ¢ 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.¢ Begin with comprehensive assessment of Lasley ey<1U(=alqUl)] p16) inspection, palpation, percussion, and auscultation (IPPA.) * Include in the assessment, collection of information from the patient, family, existing health records (such as checklist/flow sheets, laboratory results and other health care providers.= ¢ Establish a focus of care, to be addressed in the Progress Notes. = * Document the four elements of focus charting, as necessary, 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.= ° Data is the subjective and/or objective information supporting the stated focus or describing the observation at the time of a significant event, = ° Action describes the nursing interventions (independent, basic and perspective) Past, present or future, = ° Response describes the patient outcome/response to interventions or describes how the care plan goals have been ElarclaseFocus note is necessary = ° 70 describe a patient’s problem/ focus/ concern from the care plan - when the purpose of the notes is to evaluate progress toward the defined patient outcome from the plan of care. = Examples: Self care 7 Skin integrity . Activity tolerance= ° To identify an exception to the expected outcome - when the significant finding or an outcome is not expected (the exception). = Examples: Wheezes left base Nausea= ° To document a new finding - 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. (These may be “temporary foci” which do not need to be incorporated on the plan of care because they can quickly be resolved. Even if you are uncertain whether the sign or symptom is important, it is valuable to communicate the information to the health care team.)= ° To document an acute change in patient's condition - when there has been an event of new patient condition. = Examples: Respiratory distress Seizure Code blue= ° To document a significant event or unusual episode in patient care - when (a) responsibility for patient care changes from one department to another (b) a significant treatment. Intervention took place. = Examples: Admission Pre-(specify procedure) assessment Post-(specify procedure) assessment ta reli SNS nL Discharge planning Discharge status Transfusion RBC Begin thrombolytic therapy PRN medication required= ° To document an activity or treatment that Was not carried out - when treatment or activity in the flow sheet was not provided to the patient or was different from the standard of care. = ° To describe all specific patient/ family teaching - this is in compliance with a standard of care.= ° To identify the discipline making the entry as well as the topic of the note - when all members of the patient care team use on patient programs record. = Examples: Social service/ financial assistance Dietitian. Instruct low fat diet Physical therapy/ (ol fej cola Yeel ate)= ° To best describe patient's condition in relation to medical diagnosis - when the patient's focus is the pathophysiology rather than pataient’s response to the problem. This happens most frequently in highly technical Eleselssieleg-}seg ile] ne] n == * Data statements contain objective and/or subjective information. = * Action statement contains only nursing interventions (basic, perspective, independent) Yeh) Rooin) Moma ULM Ton = ¢ Patient outcome are evident in the response statements.= * Data, Action, Response only contain information related to the focus, none of the information is extraneous (e.g. : asleep, watching TV, visited by family). = * Response statements are documented after PRN medications are administered.= * Information from all these categories (Data, Action, and Response) should be used only as they are relevant or available. However all appropriate information should be included to ensure complete documentation. = ° DATA and ACTION are responded at one hour and RESPONSE is not added unti iceman Molle alee Meo em ISTH ipleyDATE/TIME Loe yO} (0s) 10 am FOCUS | DATA, ACTION and (eite4 Pain Chest Pain RESPONSE D: “Sumasakit ang dibdib ko.’ Midclavicular line pain of 4 on scale of 5 A; Medicated with Isordil 5mg, SL re els ma Girone Maelo! sakit ng dibdib ko. Rating of 2.” SE a© Response is used alone to indicate a care of plan goal has been accomplished. Lely ( DATE/TIME 03/15/08 1pm FOCUS Health Teaching: Dressiale) Change DATA, ACTION and RESPONSE R; Patient demonstrates he is able to change his own abdominal cressing using aseptic technique S; Lampe, RN= DATAis used when the purpose of the note is to document assessment finding and there is no flow sheet/ checklist for that purpose. cla ios DATE/TIME inele tis) DATA, ACTION and RESPONSE 03/18/09 oon Post transfer Assess- iene D; Received from the RR via stretcher, awake and alert, vital signs stable, IV right forearm roeetn em ole ter te lal el eng Cea oom gnc Socat lel eu kA SIC Secuencia ene SARE) Cen EA° ACTION and RESPONSE are repeated without additional data to show the sequence of decision making based on evaluating patient response to the initial intervention. me peu) 03/22/08 10:00pm FOCUS| DATA, ACTION and ses Ne cen concen ecmcn einen) Miah acestreleraeur bin Geicenteda Abdomen round and soft, Ge etces ue )elees eves bowel sounds. A; Gastrostomy bag lowered, Gear Mielec canoe Approximately 200 cc golden fluid fare eure nieCont. DATE/TIME | FOCUS DATA, ACTION and RESPONSE 03/22/08 Nausea reese casa ie: eeymlevels 10:00pm ton eel Onis y Monitor how long bag is ofr hls eset) Document any discomfort. Patient instructed to call nurse when he is uncomfortable. R: “L understand plan.” S. east= “Begin the note with ACTION when the patient's interaction begins with intervention or when including date would be unnecessary repetition. Example: DATE/TIME FOCUS DATA, ACTION and RESPONSE 03/01/08 2:20 pm Health Teaching Digoxin A; Patient instructed on the actions and side effects of digoxin. Given digoxin information card, Discusses Pie Mnionlehe hats pysteru) Elmar ae nut elt R: Return demonstration of radial Pues Date ec uh retires fos ett oN etDO’s DON'T’s Dieter RN ileo tiles providers have written before providing care and before charting * DO time and date all entries. * DO use flow sheet/ (epete sem ers oie veoderelelt(e)A) on flow sheet/ checklist current. DO chart as you make observations. * DON'T begin charting until you check the name and identifying number oan the Patient's chart on each page. * DON'T chart procedures or chart in advance. ° DON'T clutter notes with repetitive or frequently changing data already charted on the flow sheet/ checklist.DO's DON’T’s * DO write your own observations and sign over printed name. Sign and Uinlisr-l RV nVcnlenya * DO describe patient’s behavior. « DO use direct patient quotes when appropriate. * DO be factual and complete, Record exactly what happens to patient and care given. * DON’T make or sign an entry for someone else. DON'T change an entry because someone tell you to. * DON'T label a patient or show bias. * DON'T try to cover up a mistake or accident by inaccuracy or omission. + DON'T “white out” or crasc an error. * DON'T throw away notes ie eCOmeA A ASUDO's oto) a ats Nene ene ate error mark this entry as “ERROR” Ele sik oars + DO use next available line to ie * DO document patient's current Be tices sens keds el care and treatments. BoM iraieell=cyio Noted standard chart forms, + DO use only approved Eee Leos Le Gree aes eaes eee momo ed who forgot to chart. DON’T write Tere OTe) am tisedan eine sso Eels e een enses aon Nickerie ed mtsedecs del ae ose pencil