DEFINITIONS:
Focus Charting - is a method for organizing health information in the individual's
record. It is a systematic approach to documentation, using nursing terminology to
describe individual's health status and nursing action.
Focus
• a key word or diagnostic category from a nursing diagnosis or collaborative
problem on the plan of care (action plan),
i.e. skin integrity, coping, activity tolerance, self care deficit
• a current individual concern or behavior,
i.e. nausea, chest pain, pre-op teaching, hospital admission
• a sign or symptom of (possible) importance to the nursing and/or medical
diagnosis or treatment plan,
i.e. fever, constipation, hypertension, incontinence, lethargy
• an acute change in an individual's condition,
i.e. respiratory distress, seizure, fever, discomfort
• a significant event in an individual's care,
i.e. begin treatment regimen (oxygen), change in diet, catheterization
• a key word or phrase indicating compliance with a standard of care or agency
policy,
i.e. self medication teaching plan, transition
COMPONENTS OF A FOCUS NOTE:
Data: Subjective and/or objective information supporting the stated focus or describing
observations at the time of significant events.
Action: Nursing interventions performed, planned to be performed, and/or protocols and
procedures initiated.
Response: Description of individual's response to medical and/or nursing care. Statement
that the Action Plan of Care outcomes have been attained or are progressing toward
attainment.
Example:
Need: Comfort (or, Relief of pain)
D - Complaining of continuous, sharp pain in mid-abdominal incisional area. Crying. "I
need something for pain now!" States pain is 9 on a scale of 10.
A - Medicated with Demerol 75mg IM in LUOQ of left buttock. Repositioned on right
side with pillow to abdomen to help splint wound.
R - Patient stated pain was "much better" 30 minutes later and rated it 3 on a scale of
10.---N. Nurse
General Survey
• Appearance of the patient, condition- when seeing the patient
• Any IVF or Medications attaches to the arms of the patient
• Current Vital Signs of the Patient
Eg.
 Approached sitting on bed, awake, responsive, coherent with ease in
respiration, with O2 at 2 LPM, with an IVF of 4 PLR 1L + 8.25 meq KCl @

66 ugtts/min infusing well at the Right arm, with the following V/S: BP=
110/70 mmHG, PR= 100 bpm, RR= 26 cpm, T= 36.8 degree Celsius/axilla.
 Followed by F-DAR
 After writing the F-DAR , at the end of the shift write again your general
observation/survey of the patient condition
F: Hyperthermia
D: > increase in body temperature above normal range to T= 38 degree Celsius/axilla
> flushed skin and warm to touched
A: 9:00am
> Tepid sponge bath done
> instructed SO to let patient wear loose clothing
> instructed SO to provide blanket to patient when shiver
> instructed SO to let patient drink lots of fluid
> instructed SO to include in his diet foods rich in Vitamin C such as oranges
> provided opportunity for patient to rest
> due meds given
R: 1:00pm
> patient was able to rest
> patient temperature decrease to T= 37.8 degree Celsius/axilla
F1: Ineffective Breathing Pattern
D1: increase respiratory rate of 24 cpm
D2: use of accessory muscle to breath
D3: presence of nonproductive cough
F2: Hyperthermia
D1: skin warm and flush to touched
D2: increased body temperature of T= 37.7 degree celsius/axilla
F3: Fatigue
D1: less movement noted with the verbalization of “kapoy man ako lawas, kulangan ko
ug katulog”
A: 9:00am
 monitored v/s and charted
 regulated IVF and charted
 morning care done
 assessed patient needs and performed handwashing before handling the patient
 advised SO to always stay on patient bedside
 promote proper ventilation and a therapeutic environment
 elevated the head of the bed (moderate high back rest)
 provided comfort measures and provide opportunity for patient to rest
 due meds given
9:30am
 tepid sponge bath done
 instructed SO to provide blanket and let patient wear loose clothing
F4: Discharge Plan (12:00nn)

D1: discharged order given by Dr.Name/Time
M – advised SO to give the ff. meds at the right time, dose, frequency and route
E – encouraged to maintain cleanliness of the house and surroundings
T – advised to go to follow-up consultations on the prescribed date
H – encouraged to do chest tapping to facilitate mobilization of secretion
O - observed for signs of super infections such as fever, black fury tongue and foul odor
discharges
D – encouraged to eat fresh vegetables and fish
S – advised to continue praying to God and hear mass on Sunday
2:00pm – out of the room per wheelchair with improved condition
Discharge plan for patient who undergo Surgery
H – Health Teachings
A – Anticipatory Guidance
S - Spirituality
M - Medications
I – Incision in Care
N - Nutrition
E - Environment