Focus Charting

ByMa. Claudette L. Orense R.N

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

• S = subjective data (e.g., how does the

client feel?)
• O = objective data (e.g., results of the
physical exam, relevant vital signs)
• A = assessment (e.g., what is the client’s
status?)
• P = plan (e.g., does the plan stay the
same? is a change needed?)
• I = intervention (e.g., what occurred?
what did the nurse do?)
• E = evaluation (e.g., what is the client
outcome following the intervention?)
• R = revision (e.g., what changes are
needed to the care plan?)
NARRATIVE REPORT
• Narrative charting is a method in
which nursing interventions 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
• Chronologic account written in
paragraphs describing client’s status,
interventions, treatments , and the
client’s response to treatments
• Most flexible
 Disadvantage of
Narrative Charting
• Subjectivity
• Client’s problem may be difficult to
track
• Often fails to reflect the nursing
process
 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