FOCUS CHARTING

INTRODUCTION
The quality of records maintained by nurses is a reflection of the quality of care provided by them to patients/clients.

INTRO
Nurses are professionally and legally accountable for the standard of practice which they deliver and to which they contribute. Good practice in record management is an integral part of quality nursing practice.

The best offense is a good defense. In the world of nursing and Malpractice, the best way to avoid having to defend yourself in court is to chart factually and defensively.

METHODS (STYLES) OF CHARTING

NARRATIVE SOAP SOAPIER FOCUS DATA ACTION RESPONSE PIE EXCEPTION CHARTING

NARRATIVE
CHRONOLOGICAL BASELINE CHARTED Q SHIFT

LENGTHY, TIME-CONSUMING

SEPARATE PAGES FOR EACH SOURCE-ORIENTED

SOAP

USED FOR PROBLEM-ORIENTED CHARTS

S SUBJECTIVE. WHAT PT TELLS YOU. 0 OBJECTIVE. WHAT YOU OBSERVE, SEE. A ASSESSMENT. WHAT YOU THINK IS GOING ON BASED ON YOUR DATA. P PLAN. WHAT YOU ARE GOING TO DO. CAN ADD TO BETTER REFLECT NURSING PROCESS I INTERVENTION (SPECIFIC INTERVENTIONS IMPLEMENTED) E EVALUATION. PT RESPONSE TO INTERVENTIONS. R REVISION. CHANGES IN TREATMENT.

EXAMPLE OF SOAP CHARTING

#1 ALTERATION IN COMFORT. ABDOMINAL PAIN. S COMPLAINS OF PAIN IN RUQ O IS PALE AND HOLDING RIGHT SIDE A RECURRING ABDOMINAL PAIN P PUT ON NPO AND NOTIFY PHYSICIAN

THIS INVOLVES KNOWING

How to chart What to chart When to chart Who should chart

HOW TO CHART
Rule # 1: Stick to the facts Record only what you 1. See 2. Hear 3. Smell 4. Measure and Count not what you 1. Infer /Assume (opinions)

HOW TO CHART..
Ex. If the pt. pulled out his IV line, but you did not witness him doing Chart subjective data only when its supported by documented facts.

HOW TO CHART..
Rule # 2: Avoid labeling. Objectively describe the patients behavior instead of subjectively labeling it.

HOW TO CHART..
Rule # 3: Be specific. 3.1 Your charting goal is to present the facts clearly and concisely. 3.2 Use only approved abbreviations and observations in a quantifiable terms. 3.3 Eliminate bias.

HOW TO CHART..
Rule # 4: keep the record intact.

WHAT TO CHART

Rule # 1 Chart significant Situations

WHAT TO CHART
Rule # 2 Chart complete Assessment data

WHEN TO CHART
Rule # 1: Document nursing care when you perform it or shortly afterwards. Never document ahead of time.

WHO SHOULD CHART?

Rule # 1: No matter how busy you are, never ask another nurse to complete your charting.

WHAT SHOULD BE
DOCUMENTED Environmental factors ( safety,equipment ),self care, Client education Clients outcomes , clients response to treatments, or preventive care Discharge assessment data More comprehensive notations to clients who are seriously ill All relevant assessment data, including monitoring Strips Information related any client transports

WHAT SHOULD BE DOCUMENTED?

Collaboration / communication with other health care providers Medication administration Verbal orders Telephone orders

FOCUS CHARTING
Describes the patients perspective and focuses on documenting the patients current status, progress towards goals, and response to INTERVENTIONS.

FOCUS CHARTING
Is a method for organizing health information of The individuals record. It is a systematic approach to documentation, using nursing terminology to describe individuals status and nursing action.

PURPOSES
-

Brings the focus of care back to the patient and patients concern Instead of a problem list, or list of medical and nursing dx, a focus column is used that incorporates many aspects of patient and patient care.

OBJECTIVE
1. To easily identify critical patient issues / Concerns in the progress notes. 2. To facilitate Communication among all Disciplines.

GENERAL GUIDELINES
1.Focus charting must be evident at least once every shift. 2. 1.Focus charting must be patient-oriented not nursing task-oriented. 3. Document only patients concern and/or plan of care. Ex. Health teaching per shift

GENERAL GUIDELINES .
4. Document patients status on admission, for every transfer to/from another unit or discharge. 5. Follow the dos of documentation. 6. For eight hours shift, use blue or black ink for morning and afternoon shifts, red ink for night shift.

SPECIFIC GUIDELINES
1.

2.

Begin with comprehensive assessment of the patients using 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, lab results and that of other health care providers.

SPECIFIC GUIDELINES.
3. Establish a focus of care, to be addressed in the Progress notes.

FOCUS
current individual concern or behavior, ex. Nausea, Chest pain  A sign or symptoms of importance to the nursing, medical diagnosis, or treatment plan, Ex. Fever, Constipation
A

FOCUS
An acute change in an individuals condition ex.Respiratory distress, seizure  A significant event in an individuals care ex. Change in diet catheterization  A key word or phrase indicating compliance with standard care or policy.


Ex. teaching plan

FOCUS.
 The

focus might be patient strength, problem,

or need.  Topics that may appear in the focus Column include patients concern and behaviors; Therapies and responses; changes of condition;  Significant events such as teaching, consultation, Monitoring, management of activities of daily living or assessment of functional health patterns.

FOCUS CHARTING
NARRATIVE DOCUMENTATION (DAR)

USES

DATA SUBJECTIVE OR OBJECTIVE THAT SUPPORTS THE FOCUS (CONCERN) ACTION NURSING INTERVENTION RESPONSE PT RESPONSE TO INTERVENTION

FOCUS.
The narrative portion of focus charting includes Data, Action and Response ( D A R ).

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, future.

RESPONSE.
- Describes the patient outcome/response to interventions or describes how the care plan goals have been attained.

FOCUS NOTE
1. Is necessary to describe a patients problem/focus/concern from the care plan- when the purpose of the note is to evaluate progress toward the defined patient outcome from the plan of care. Ex. - self-care - Skin integrity - Activity tolerance

FOCUS NOTE
2. To document a finding- when the purpose of the new note is to document a new sign or symptom or a new behavior which is the current focus of care. 3. To document an acute change in patients conditionwhen there has been an event of new patient condition. Ex. - Respiratory distress - Seizure

PURPOSE

(a) responsibility for patient care changes from one department to another to document a significant event or unusual episode in a patient care (b) when a significant treatment/intervention took place.

E X.

Admission Pre-(specify procedure) assessment Post-(specify procedure) assessment Pre-transfer assessment 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.

ex. - Social service/financial assistance Dietitian/instruct low fat diet Physical therapy/crutch walking

To best describe patients condition in relation to medical diagnosis When the patients focus is the pathophysiology rather than patients response to the problem. This happens most frequently in highly technical areas such as critical care.

Data statements contain objective and/or subjective information. Action statement contains only nursing interventions (basic, perspective,independent) past, present or future. 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 those categories (Data, Action, 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.

Response is used alone to indicate that a care plan goal has been accomplished.

DATE/TI ME 03/08/08 7-3pm 10 am

FOC US

DATA, ACTION, RESPONSE

D: Sumasakit ang dibdib ko, Chest pain Midclavicular line pain of 4 on scale of 5

12 noon

A; Medicated with Isordil 5mg. SL. Peterson Angsingco, RN R: resting in bed. Nabawasan na ng sakit ang dibdib ko. Pain scale Rating of 2 Peterson Angsingco , RN And so on

1:05 pm

DATE / TIME 09/15/08 7-3 pm 10 AM

FOCUS

DATA, ACTION, RESPONSE

Health Teaching: Dressing Change

R: Patient demonstrated, he is able to change his own abdominal dressing using aseptic technique. Bea Alonzo, RN

EX.
DATE / TIME 19/15/08 7-3 pm 10 AM FOCUS Post Transfer Assessment DATE, ACTION, RESPONSE D: Received from RR via stretcher, awake and alert, vital signs stable. IV right forearm patent, Foley in place with clear yellow urine, dressing in RLQ is clean and dry moving all extremities voluntarily, Minimal incisional pain at this time rating 3.

ACTION AND RESPONSE EX.

DATE / TIME 09/15/08 7-3pm 9 AM FOCUS Nausea DATA, ACTION, RESPONSE D: I feel like my stomach is filling up with pressure again and I'm nauseated, Abdomen round and soft, Gastrostomy bag at body level, (rate of bowel sounds.)

Cont

A: Gastrostomy bag lowered 9:15 am R: I feel better now. Approximately 200 cc gastric fluid; returned as much flatus A: Keep gastrostomy bag below body level. Bea Alonzo, RN

BEGIN THE NOTE WITH ACTION WHEN THE PATIENTS INTERACTION BEGINS WITH
INTERVENTION OR WHEN INCLUDING DATA WOULD BE UNNECESSARY REPETITION.
DATE / TIME 09/15/08 9 AM FOCUS Health Teaching Digoxin DATA, ACTION, RESPONSE A: Patient instructed on the actions and side effects of digoxin. Given digoxin information card, discussed when he would call the physician About the medicine. R: Return demonstration of radial pulse. I understand the purpose of medication,

DATE / TIME O9/15/08 9 AM

FOCUS Pain at IV site

9:20 AM

DATA, ACTION, RESPONSE D - masakit and pinaglagyan ng IV ko, Check IV site of IV, found beginning of signs of infiltration. A Remove IV, change the whole system, reinserted the new set aseptically into the distal portion of basilic vein, left arm anchored , splint applied, advised to call nurse for any presence of pain. R Wala na ang sakit ng pinaglagyan ng IV ko.

Date/Time Focus s

Data, Action, Response Data: It hurts to take a deep breath, pain increases with activity and breathing. PCA helps; pain is sharp; pin is located at the RUQ ; vital signs: BP 144/990; pulse 108; respiration 24.....

SUMMARY

Focus charting can help you monitor patient problems and avoid repetitious documentation, a focus which may be written as a nursing diagnosis can be changed in an acute condition, a potential problem, a treatment procedure or a patient behavior.

AGAIN ..

The quality of records maintained by nurses is a reflection of the quality of care provided by them to patients/clients.

CASE 1

A patient is 8 hours post op and complaining of moderate pain at the abdominal incision site. The blood pressure is slightly elevated, 130/80. The pain medication ordered is not due for another hour.

CASE 2

. A patient has COPD. He constantly complaints of coughing, fatigue and sputum production. During the assessment, the nurse observes his breathing pattern. She notes the barrel-chest that is common in COPD patients.

CASE 3
A patient is transferred to the medicalsurgical ward for congestive heart failure. Shortly after admission, the nurse assesses his condition. He is dyspneic and slightly cyanotic.

CASE 4
Post-operatively a patient voids 50 ml of clear yellow urine three times, but continuous to complain that the bladder does not feel empty.

Thank you and God bless !!!

Elvira Cachuela- Atuel, RN, MAN, US-RN