1.
Focus Charting

2.
Focus charting describes the patient’s
perspective and focuses on documenting
the patient’s current status, progress
towards goals and response to
interventions.

3.
 Purpose
  Focus charting brings the focus of care
back to the patient and the patients’
concerns. Instead of a problem list or list
of nursing and medical diagnosis, a focus
column is used that incorporates many
aspects of patient and patient care.

4.
 The focus might be patient
strength, problem, or need. Topics that
may appear in the focus column include
patients’ concerns and behaviors;
therapies and responses; significant
events such as
teaching, consultation, monitoring, manag
ement of activities of daily living or
assessment of functional health patterns.

5.
 The narrative portion of focus charting
includes Data, Action and Response (D
A R). The principal advantage of focus
charting is in the holistic emphasis on the
patient and his/her priorities including
ease in charting.

6.
 Objectives
  To easily identify critical patient issues/
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 flowsheet/ checklist.

7.
 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 of
notes:
 ° Focus note written on the second column.
 ° Data, Action and Response on the third
column.

8.
  Sign name (e.g. M. Aquino, RN) 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 or discharge.

9.
  Follow the do’s of documentation.
  For eight hours shift, use blue or black
ink for morning and afternoon shift, red
ink for night shift.
  For twelve hours shift, use blue or black
ink for morning and red ink for night shift.

10.
 Specific Guidelines
  Begin with comprehensive assessment of
the patient 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, laboratory
results and other health care providers.

11.
  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.

12.
 ° 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.
 ° Response describes the patient
outcome/response to interventions or
describes how the care plan goals have been
attained.

13.
Focus note is 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

14.
 ° To identify an exception to the expected
outcome - when the significant finding or an
outcome is not expected (the exception).
 Examples: Wheezes left base
Nausea

15.
 ° 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
“temporary foci” which do not need to be
incorporated on the plan of care because they
can quickly be 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.)

16.
 ° To document an acute change in patient’s
condition - when there has been an event of
new patient condition.
 Examples: Respiratory distress
Seizure
Code blue

17.
 ° To document a significant event or unusual episode in
patient care - when (a) responsibility for patient care
changes from one department to another (b) a
significant treatment. Intervention took place.
 Examples: Admission
Pre-(specify procedure) assessment
Post-(specify procedure) assessment
Pre-transfer assessment
Discharge planning
Discharge status
Transfusion RBC
Begin thrombolytic therapy
PRN medication required

18.
 ° 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.

19.
 ° To identify the discipline making the entry
as well as the topic of the note - when all
members of the patient care team use on
patient programs record.
 Examples: Social service/ financial
assistance
Dietitian. Instruct low fat diet
Physical therapy/
crutchwalking

20.
 ° To best describe patient’s condition in
relation to medical diagnosis - when the
patient’s focus is the pathophysiology rather
than pataient’s response to the problem. This
happens most frequently in highly technical
areas such as critical care.

21.
  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.

22.
  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.

23.
  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.

24.
Examples of Focus Charting:
DATE/TIME FOCUS DATA, ACTION and
RESPONSE
03/08/08 Chest D: “Sumasakit ang dibdib ko.”
Midclavicular line pain of 4 on scale
10 am Pain of 5
A: Medicated with Isordil 5mg. SL.
S: Lampe, RN
12:00 am Chest Pain R: resting in bed. “nabawasan na
sakit ng dibdib ko. Rating of 2.”
S: Lampe, RN

25.
 ° Response is used alone to indicate a care of plan goal
has been accomplished.
 Example:
DATE/TIME FOCUS DATA, ACTION and
RESPONSE
03/15/08 Health R: Patient demonstrates
1 pm Teaching: he is able to change his
Dressing own abdominal dressing
Change using aseptic technique
S: Lampe, RN

26.
 DATA is used when the purpose of the note is to
document assessment finding and there is no
flow sheet/ checklist for that purpose.
 Example:
DATE/TIME FOCUS DATA, ACTION and
RESPONSE
03/18/09 Post D: Received from the RR via
stretcher, awake and alert, vital
2:20 pm transfer signs stable, IV right forearm
Assess- patent, foley catheter in place with
clear yellow urine, dressing on
ment RLQ is clean and dry, moving all
extremities voluntarily. “Minimal
incisional pain at this time rating
of 3.”
S: Lampe, RN

27.
 ° ACTION and RESPONSE are repeated without
additional data to show the sequence of decision making
based on evaluating patient response to the initial
intervention.
 Example:
DATE/TIME FOCUS DATA, ACTION and
RESPONSE
03/22/08 Nausea D: “I feel like my stomach is filling up
with pressure again and I’m
10:00pm nauseated.”
Abdomen round and soft,
gastrostomy bag at body level. Rare
bowel sounds.
A: Gastrostomy bag lowered.
R: “I feel like better now.”
Approximately 200 cc golden fluid
returned as much flatus

28.
Cont.
DATE/TIME FOCUS DATA, ACTION and
RESPONSE
03/22/08 Nausea A: Keep gastrostomy bag at
body level.
10:00pm Monitor abdominal status.
Monitor how long bag is
tolerated at body level.
Document any discomfort.
Patient instructed to call nurse
when he is uncomfortable.
R: “I understand plan.” S.
Lampe, RN

29.
 °Begin the note with ACTION when the patient’s
interaction begins with intervention or when
including date would be unnecessary repetition.
Example:
DATE/TIME FOCUS DATA, ACTION and
RESPONSE
03/01/08 Health A: Patient instructed on the actions
and side effects of digoxin. Given
2:20 pm Teaching digoxin information card. Discusses
when he would call the physician
Digoxin about the medicine.
R: Return demonstration of radial
pulse.
“I understand the purpose of
medication.” S Lampe, RN

30.
Documentation DO’s and
DONT’s
DO’s DON’T’s
 DO read what other  DON’T begin charting until
providers have written you check the name and
before providing care and identifying number on the
before charting patient’s chart on each page.
 DO time and date all  DON’T chart procedures or
entries. chart in advance.
 DO use flow sheet/  DON’T clutter notes with
checklist. Keep information repetitive or frequently
on flow sheet/ checklist changing data already
current. DO chart as you charted on the flow sheet/
make observations. checklist.

31.
DO’s DON’T’s
 DO write your own  DON’T make or sign an
observations and sign over entry for someone else.
printed name. Sign and DON’T change an entry
initial every entry. because someone tell you to.
 DO describe patient’s  DON’T label a patient or
behavior. show bias.
 DO use direct patient  DON’T try to cover up a
quotes when appropriate. mistake or accident by
 DO be factual and inaccuracy or omission.
complete. Record exactly  DON’T “white out” or erase
what happens to patient and an error.
care given.  DON’T throw away notes
with an error on them.

32.
DO’s DON’T’s
 DO draw a single line thru an  DON’T squeeze in a issed entry
error mark this entry as “ERROR” or “leave space” for someone else
and sign your name. who forgot to chart. DON’T write
 DO use next available line to in the margin.
chart.  DON’T use meaningless words
 DO document patient’s current and phrases, such as “good day” or
status and response to medical “no complaints.”
care and treatments.  DON’T use notebook, paper or
 DO write legibly. DO use pencil
standard chart forms.
 DO use only approved
abbreviations.