FOCUS CHARTING

Nursing as a profession…
Assumes accountability for nursing action
Nursing accountability
-Apply concepts learned for nursing action geared towards patient’s needs
Identifying patient’s needs…
Leads to well-planned, individualized, effective nursing care
Remember…
DOCUMENTING is PATIENT CARE
The GOLDEN RULE:
-WHAT is written was done, and what was done must be written.
Purposes of Nursing Records
• communication tool for healthcare team
•Legal document
•Financial billing
•Education
•Assessment
•Research
•Auditing and monitoring
FOCUS CHARTING
Identifies patient-centered concerns, issues and problems
Focus Charting—DAR
•DATA
Subjective and objective data that supports the focus
Assessment phase of the nursing process

•ACTION
Interventions, such as medication, treatment, calls to the physician, and patient teaching.
Planning and implementation phase of the nursing process

•RESPONSE
Patient’s response to your interventions
Evaluation phase of the nursing process
What can be your FOCUS?
1. A patient’s problem/focus or concern from the nursing care plan-when the purpose of the
note is to evaluate progress toward the defined patient outcome.

Example:
skin integrity
coping
activity intolerance
self-care deficit
physical mobility
tissue perfusion
airway clearance
Date/Time Focus DAR charting
August 16, 2010 F: Airway clearance D: coarse crackles
1000H on right upper
lung. unable to
bring up phlegm.
A: placed on
moderate high
back rest.
Nasotracheal
suctioning done.
Oxygenation at
2LPM as ordered
via nasal cannula.
R: suctioned thick
yellowish mucous
plenty in amount.
Able to sleep after.
A San Antonio RN
What can be your focus?
2. A new finding– to document a new sign and symptom or behavior which is the current focus
of care.
Example:
constipation
Diarrhea
Wheezes
Hematoma
Chest pain
Nausea
bleeding
Date/time Focus DAR charting
August 16, 2010 chest pain D: patient complained of
0700H mid-sternal pain
radiating to the left,
stabbing with a pain
scale of 7/10.
A: hooked to cardiac
monitor. Monitored v/s.
oxygenation at 4LPM via
nasal cannula. Referred
to MOD. Medicated with
Morphine SO4 10 mg IV
as ordered.
R: rested in bed, v/s
taken, BP 130/90 HR
78/min, regular rate and
rhythm. Patient stated
pain decreased to rating
of 3/10. A San Antonio
RN
.
What can be your focus?
An acute change in a patient’s condition.
Example:
Respiratory distress
Seizure
Fever/hyperthermia
Discomfort
What can be your focus?
A significant event or unusual episode in patient care when:
a. Responsibility for patient care changes from one department to another
Example:
Admission
Pre-(specify procedure) assessment
Post -(specify procedure) assessment
Pre and post transfer assessment
Code blue or code red
Date/time Focus DAR charting
August 16, 2010 F:admission D: 56 y/o female
0800H admitted from ER per
wheelchair with an IVF of
D5LR on right metacarpal
vein using g22 abbocath
regulated to 20gtts/min
infusing well.
A: assisted comfortably
in bed ,nursing health
history taken. Oriented
to hospital policies. Initial
vs taken.
R: patient responded
positively to orientation,
expressed desire to be
seen by her attending
physician.A San Antonio
RN
What can be your focus?
b. A significant treatment/ intervention took place
Example:
Begin treatment regimen (begin thrombolytic therapy)
Begin oxygen therapy
Blood transfusion
Change in dieti
Catheterization
IV insertion
Intubation
Date/time focus DAR charting
August 16, 2010 Blood transfusion D: bloody CT drain of
0900H 100ml/hr, patient is pale
looking, hemoglobin
level taken 7 mg/dl.
A:blood transfusion of 1
unit PRBC SN
NVBSP201000 started at
1000H to run for 4 hours.
Initial VS taken prior to
transfusion.(please see
blood transfusion sheet).
Observed for protocol on
blood transfusion.
R: BT ended at1400H. VS
monitored throughout
the procedure, stable. No
untoward signs and
symptoms noted. A San
Antonio RN
What can be your focus?
An activity or treatment that was not carried out or performed, or client’s refusal to allow
treatment or take medication.
Example:
Refusal of medication
Refusal of iv insertion
Refusal to raise siderails
Loss of appetite
Wound drainage
Date/time Focus DAR charting
August 16, 2010 Refusal to raise siderails D: informed the patient
1100H the need to raise siderails
up, however, patient
verbalized “don’t put me
inside this cage, I will not
fall anyway”
A:explained that it’s a
hospital protocol to have
bed siderails up
especially at night time
for safety . However,the
patient insisted there’s
no need because she will
not fall. Notified MD and
supervisor.
R: agreed to sign the
waiver for refusal.
Waiver attached to chart,
endorsed to incoming
shift for continuity of
care.
What can be your focus?
All specifics regarding patient and family teachings—health teachings or other relevant
instructions given to the patient.
Example:
Diet restrictions
Feeding
Medication (specify)
Discharge instructions
Date/time Focus DAR charting
August 16, 2010 F: Health teaching: D: patient queried about
1200H medication (Lanoxin) the new medicine he is
taking that his doctor
told him about.
A: informed patient
about Lanoxin which he
is supposed to take 2x a
day, and that it makes
the heart pump better.
Explained the need to
take his full minute heart
rate before taking the
medicine.
R: expressed
understanding by return
demo on how he should
take the heart rate by
using the radial pulse. A
San Antonio RN
What can be your focus?
Members of the health team who made a note or entry in the patient’s chart—chart what you
feel is important data from visits made by physician especially referrals and from other members
of the health care team such as:
Dietitian
Social worker
Chaplain
Physical rehabilitation and others
Example:
Social service-financial assistance
Dietitian-diet instructions
Physical rehabilitation- instructions on crutch walking
Date/time Focus DAR charting
August 16, 2010 F: Dietitian- D:MD ordered for
1300H instruction on low low fat diet .
fat diet A:Informed
dietitian regarding
new order for diet.
Requested to
conduct
counselling/instruc
tions regardiing
dietary regimen.
R: dietitian
conducted dietary
counselling at the
bedside with the
presence of wife. A
San Antonio RN
What can be your focus?
Patient’s condition related to his/her medical diagnosis—a sign or symptom which is of
(possible) importance to the nursing and or medical diagnosis and treatment plan.
Example:
Hyperkalemia
Hypertension
Arrhythmia
Hypoglycemia
Incontinence
Retention
Date/time Focus DAR charting

August 16,2010 F: Arrhythmia-bigeminy D: bigeminy noted in

1400H scope. CR 65 to 70bpm
BP 110/70mmHg
A: obtained tracing and
referred to
MD.continuous cardiac
rhythm monitoring.
Monitored for bp and
urine output. Standby
Lidocaine at the bedside
as ordered. Blood for
serum determination
sent to laboratory.
R: still with periodic
episodes of bigeminy but
bp remains stable.
Patient rested, no
untoward manifestations
noted. A San Antonio RN
Remember…
Data and action are recorded at one hour
Response is not added until later, when the patient’s outcome is evident.

Date/time Focus DAR charting

August 16, 2010 F: fever D: “ang init ng

1500H pakiramdam ko”
temperature taken via
axilla- 39 centigrade.
Flushed skin, warm to
touch.
A: cooling measures
provided-sponge bath
rendered, changed with
lighter clothing, increase
fluid intake encouraged.
A San Antonio RN

1700H fever R: latest temperature

taken per axilla-37.6
centigrade.A San
Antonio RN
Remember…
Response is used alone to indicate that a care plan goal has been accomplished

Date/time Focus DAR charting

August 16, 2010 Health teaching: R: patient
1800H taking of pulse demonstrated he is
able to take his
pulse by using the
radial pulse.
Checked with the
patient accuracy of
pulse rate taken.
A San Antonio RN
Remember…
Data is used alone when the purpose of the note is to document assessment finding and there is
no flow sheet/checklist for that purpose.

Date/time Focus DAR charting

August 16, 2010 Post-transfer D: received from RR
2000H assessment via stretcher,
awake and alert,
vital signs stable. IV
on right arm
patent. Foley
catheter in place
with clear yellow
urine, dressing on
RLQ clean and dry,
moving all
extremities
voluntarily.
A San Antonio RN
Remember…
Begin the note with ACTION when the patient’s interaction begins with intervention or when
including data would be unnecessary repetition.

Date/time Focus DAR charting

August 16D2010 Health teaching: A: patient
2100H Digoxin instructed on the
actions and side
effects of Digoxin.
Given Digoxin
information guide.
Discussed when he
would call the
physician about the
medicine.
R: returned
demonstration of
radial pulse. Patient
expressed: “I
understand the
purpose of the
medication.”
A San Antonio RN
The DO’s of Charting
•Do check the name and identifying number on the patient’s chart and on each page
•Do read what other providers have written before charting your care
•Do time and date all entries
•Do chart legibly
The DO’s of Charting
•Avoid errors in grammar and spelling
•Do keep all patient data strictly confidential
•Do be factual, specific and complete
Use direct patient quotes when appropriate
Record what you see, hear, smell, feel, measure and count
The DO’s of Charting
•Do sign in your name immediately after the last word of your entry
•Do use only commonly used or approved abbeviations and symbols
•Do document outcomes of nursing intervention to show effectiveness of care
•Do document discharge instructions including:
 Referrals to other health agencies and community providers
 Any patient teaching that was done.
The Do’s of Charting
•Do write entries in order of consecutive shifts and days. Document the date and time for each
entry you write.
•Do document the patient’s refusal of treatment and your patient teaching about the need for
treatment and possible consequences of refusal.
The Do’s of Charting
•Do record each phone call to or from a physician, including exact time, message and response
•Do chart as soon as possible after giving care
•Do chart precautions or preventive measure used
Pitfalls of Documentation
•Writing legibly could lead to errors, misunderstanding
•Leaving blank lines: someone could insert info at a later date
•Altering someone else’s notes
•Back dating records
Pitfalls of Documentation
•Using immeasurable terms: each entry should reflect clarity and brevity (use as few words as
possible)
•Failing to document communication with other healthcare members regarding client care:
Remember: IF IT WAS NOT DOCUMENTED, IT WAS NOT DONE
Pitfalls of Documentation
•Correcting errors incorrectly: only draw a single line through error and write “error” above it
with nurse’s initial
•Inserting info between lines : big NO NO
•Documenting for someone else: each nurse should only document their own care and
observations
•Expressing opinions
Pointers To remember
•If you remember an miportant point after you’ve completed
•Your documentation, chart the information with a notation that it’s a “late entry”
•Include the date and time of the late entry
•If the information on a form such as the Flowsheet or Kardex doesn’t apply to your client,
write NA (not applicable) on the space provided
Points to remember
•When documentation continues from one page to another, sign the bottom of the first page,
write the date, time and continued from previous page
•Include the following information when documenting nursing procedures:
What procedure?
When?
Where?
Who performed?
Patient’s response to the procedure? (adverse reaction to the procedure, if any)
 Questions?
•What if my patient has no problem?
•What if my patient is for home already and just cannot settle yet the bill?
FOCUS IT WELL…