FOCUS CHARTING

(FDAR)

FOCUS CHARTING

•Describes the patient’s perspective and focuses on documenting the patient’s current status, progress towards goals and response to interventions

PURPOSE

• FOCUS CHARTING brings the focus of care back to the patient and the patient’s concerns. Instead of a problem list or list of nursing or 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 include patient’s concerns and behaviors, therapies and responses, significant events such as teaching, consultation, monitoring, management of activities of daily living or assessment of functional health patterns

• The narrative portion of focus charting includes Data, Action and Response (DAR)

• The principal advantage of focus charting is in the holistic emphasis on the patient and his/her priorities

OBJECTIVES

• To easily identify critical patient issues or concerns in the progress notes

• To facilitate communication among all disciplines

• To improve time efficiency with documentation

• To improve concise entries that would not duplicate patient information already provided on the flowsheet/checklist

GENERAL GUIDELINES

• Focus charting must be evident at least once every shift

• 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 notes

• Focus notes – written on the second column

• Data, Action and Response – third column

GENERAL GUIDELINES

• Sign name 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 and for discharge

GENERAL GUIDELINES

• Follow the do’s of documentation (discussed later)

• For 8-hours shift, use blue or black ink for morning or afternoon shift, and red ink for night shift

• For 12-hours shift, use blue or black ink for morning shift, and red ink for night shift

SPECIFIC GUIDELINES

•Begin with comprehensive assessment of the patient using inspection, palpation, percussion and auscultation

• Include in the assessment, collection of information from the patient, family, existing health records (such as checklist/ flow sheet, laboratory results)

SPECIFIC GUIDELINES

• 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

SPECIFIC GUIDELINES

•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

SPECIFIC GUIDELINES

•Response describes the patient outcome/response to the interventions or describes how the care plan goals have been attained

• Focus notes are necessary to 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

Skin integrity

Activity tolerance

• Focus notes are necessary to identify an exception to the expected outcome –when the significant finding or an outcome is unexpected (the exception)

• Examples: Wheezes, left base

Nausea

• Focus notes are necessary 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 a temporary focus which do not need to be incorporated on the plan of care because they can be quickly 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)

• Focus notes are necessary to document an acute change in the patient’s condition – when there has been an event of new patient condition

• Examples: Respiratory Distress

Seizure

Code blue

• Focus notes are necessary to document a significant event or unusual episode in patient care

• Examples: Admission

Pre-operative assessment

Post-operative assessment

Pre-transfer assessment

Discharge planning

Transfusion

PRN medication required

• Focus notes are necessary to document and 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

• Focus notes are necessary to identify the discipline making the entry as well as the topic of the note

• Examples: Social service/financial assistance

Dietitian – instruct low fat diet

Physical therapy/crutchwalking

• Focus notes are necessary to best describe the patient’s condition in relation to medical diagnosis – when the patient’s focus is the pathophysiology rather than the patient’s response to the problem (this happens most frequently in high technical areas such as critical care)

•Data statements contain objective and or subjective information

• Action statements contain only nursing interventions

• Patient outcome are evident in the response statements

•Data action and response only contain information related to the focus

• 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 until later, when the patient outcome is evident

Examples of Focus ChartingDate/ Time Focus Data, Action and Response

03/08/1410 am

Chest pain D: “sumasakit ang dibdib ko”. Midclavicular line, 4/10 on pain scale

A: Medicated with Isordil 5mg tab SL

L. Dela Cruz, RN

03/08/1412 pm

Chest Pain R: Resting in bed. “Nabawasan naang sakit ng dibdib ko”. Pain Scale 2/10.

L. Dela Cruz,RN

Response is used alone to indicate if a care of plan goal has been accomplished

Date/ Time Focus Data, Action and Response

03/15/1410 am

Health Teaching: Dressing Change

R: Patient demonstrates that he is able to change his own abdominal dressing using aseptic technique

C. Ballesteros, RN

Data is used when the purpose of the note is to document assessment finding and there is no flow sheet or checklist for that purpose

Date/ Time Focus Data, Action and Response

03/18/142pm

Post –transfer assessment

D: Received from the RR via stretcher, awake and alert. Vital signs stable. IV on right metacarpal of patient. Foley catheter in place with clear yellow urine. Dressing on RLQ is clean and dry. Patient is moving all extremities voluntarily. Minimal incisional pain, 3/5 on pain scale.

P. Apostol RN

DOCUMENTATION DOs:

• DO write your OWN observations and sign over printed name. Sign and initial every entry.

• 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

DOCUMENTATION DOs:

• DO draw a single line through an error and mark this entry as “ERROR” and sign your name.

• DO use next available line to chart

• DO document patient’s current status and response to medical care and treatments

• DO write legibly. DO use standard chart forms

• DO use only approved abbreviations

DOCUMENTATION DON’Ts:

• DON’T make or sign an entry for someone else.

• DON’T change an entry because someone told 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 erase an error

DOCUMENTATION DON’Ts:

• DON’T throw away notes with an error on them

• DON’T squeeze in a missed entry or “leave space” for someone else who forgot to chart

• DON’T write over the margin

• DON’T use meaningless words ad phrases, such as “good day” or “no complaints”

• DON’T use pencil

Thank you for Listening!