Focus Charting 2
Transcript of Focus Charting 2
![Page 1: Focus Charting 2](https://reader033.fdocuments.in/reader033/viewer/2022050617/547fb076b379593f2b8b58d6/html5/thumbnails/1.jpg)
![Page 2: Focus Charting 2](https://reader033.fdocuments.in/reader033/viewer/2022050617/547fb076b379593f2b8b58d6/html5/thumbnails/2.jpg)
Introduction
The quality of records maintained by nurses is a reflection of the quality of care provided by them to patients/clients.
![Page 3: Focus Charting 2](https://reader033.fdocuments.in/reader033/viewer/2022050617/547fb076b379593f2b8b58d6/html5/thumbnails/3.jpg)
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.
![Page 4: Focus Charting 2](https://reader033.fdocuments.in/reader033/viewer/2022050617/547fb076b379593f2b8b58d6/html5/thumbnails/4.jpg)
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.
![Page 5: Focus Charting 2](https://reader033.fdocuments.in/reader033/viewer/2022050617/547fb076b379593f2b8b58d6/html5/thumbnails/5.jpg)
METHODS (STYLES) OF CHARTING
NARRATIVE SOAP
SOAPIER FOCUS
DATA
ACTION
RESPONSE PIE EXCEPTION
CHARTING
![Page 6: Focus Charting 2](https://reader033.fdocuments.in/reader033/viewer/2022050617/547fb076b379593f2b8b58d6/html5/thumbnails/6.jpg)
NARRATIVE CHRONOLOGICAL BASELINE CHARTED Q SHIFT
LENGTHY, TIME-CONSUMING
SEPARATE PAGES FOR EACH SOURCE-ORIENTED
![Page 7: Focus Charting 2](https://reader033.fdocuments.in/reader033/viewer/2022050617/547fb076b379593f2b8b58d6/html5/thumbnails/7.jpg)
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.
![Page 8: Focus Charting 2](https://reader033.fdocuments.in/reader033/viewer/2022050617/547fb076b379593f2b8b58d6/html5/thumbnails/8.jpg)
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
![Page 9: Focus Charting 2](https://reader033.fdocuments.in/reader033/viewer/2022050617/547fb076b379593f2b8b58d6/html5/thumbnails/9.jpg)
CHARTING
Describes the patient’s perspective and focuses
on documenting the patient’s current status, progress
towards goals, and response to INTERVENTIONS.
![Page 10: Focus Charting 2](https://reader033.fdocuments.in/reader033/viewer/2022050617/547fb076b379593f2b8b58d6/html5/thumbnails/10.jpg)
CHARTING
Is a method for organizing health information of
The individuals record.
It is a systematic approach to documentation,
using nursing terminology to describeindividuals status and nursing action.
![Page 11: Focus Charting 2](https://reader033.fdocuments.in/reader033/viewer/2022050617/547fb076b379593f2b8b58d6/html5/thumbnails/11.jpg)
The importance of charting/ Proper documentation
![Page 12: Focus Charting 2](https://reader033.fdocuments.in/reader033/viewer/2022050617/547fb076b379593f2b8b58d6/html5/thumbnails/12.jpg)
This involves knowing
How to chartWhat to chartWhen to chartWho should chart
![Page 13: Focus Charting 2](https://reader033.fdocuments.in/reader033/viewer/2022050617/547fb076b379593f2b8b58d6/html5/thumbnails/13.jpg)
HOW TO CHART
Rule # 1: Stick to the factsRecord only what you1.See2.Hear3.Smell4.Measure andCount not what you1.Infer /Assume (opinions)
![Page 14: Focus Charting 2](https://reader033.fdocuments.in/reader033/viewer/2022050617/547fb076b379593f2b8b58d6/html5/thumbnails/14.jpg)
HOW TO CHART…..
Ex. If the pt. pulled out his IV line, but you did not witness him doing
Chart subjective data only when it’s supported by documented facts.
![Page 15: Focus Charting 2](https://reader033.fdocuments.in/reader033/viewer/2022050617/547fb076b379593f2b8b58d6/html5/thumbnails/15.jpg)
HOW TO CHART…..
Rule # 2: Avoid labeling.
Objectively describe the patient’s behavior instead of subjectively labeling it.
![Page 16: Focus Charting 2](https://reader033.fdocuments.in/reader033/viewer/2022050617/547fb076b379593f2b8b58d6/html5/thumbnails/16.jpg)
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.
![Page 17: Focus Charting 2](https://reader033.fdocuments.in/reader033/viewer/2022050617/547fb076b379593f2b8b58d6/html5/thumbnails/17.jpg)
HOW TO CHART…..
Rule # 4: keep the record intact.
![Page 18: Focus Charting 2](https://reader033.fdocuments.in/reader033/viewer/2022050617/547fb076b379593f2b8b58d6/html5/thumbnails/18.jpg)
What to Chart
Rule # 1 – Chart significant Situations
![Page 19: Focus Charting 2](https://reader033.fdocuments.in/reader033/viewer/2022050617/547fb076b379593f2b8b58d6/html5/thumbnails/19.jpg)
What to Chart…
Rule # 2 – Chart complete Assessment data
![Page 20: Focus Charting 2](https://reader033.fdocuments.in/reader033/viewer/2022050617/547fb076b379593f2b8b58d6/html5/thumbnails/20.jpg)
When to Chart…
Rule # 1: Document nursing care when you
perform it or shortly afterwards.
Never document ahead of time.
![Page 21: Focus Charting 2](https://reader033.fdocuments.in/reader033/viewer/2022050617/547fb076b379593f2b8b58d6/html5/thumbnails/21.jpg)
Who should Chart?
Rule # 1: No matter how busy you are, never ask another nurse to complete your charting.
![Page 22: Focus Charting 2](https://reader033.fdocuments.in/reader033/viewer/2022050617/547fb076b379593f2b8b58d6/html5/thumbnails/22.jpg)
WHAT SHOULD BE DOCUMENTED?
Environmental factors ( safety,equipment ),self care,
Client educationClients outcomes , clients response to treatments, or preventive careDischarge assessment dataMore comprehensive notations to clients whoare seriously illAll relevant assessment data, including monitoring Strips Information related any client transports
![Page 23: Focus Charting 2](https://reader033.fdocuments.in/reader033/viewer/2022050617/547fb076b379593f2b8b58d6/html5/thumbnails/23.jpg)
WHAT SHOULD BE DOCUMENTED?
Collaboration / communication with other health care providers
Medication administrationVerbal ordersTelephone orders
![Page 24: Focus Charting 2](https://reader033.fdocuments.in/reader033/viewer/2022050617/547fb076b379593f2b8b58d6/html5/thumbnails/24.jpg)
Focus Charting
![Page 25: Focus Charting 2](https://reader033.fdocuments.in/reader033/viewer/2022050617/547fb076b379593f2b8b58d6/html5/thumbnails/25.jpg)
PURPOSE of FocusCharting
- Brings the focus of care back to the patient and patient’s 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.
![Page 26: Focus Charting 2](https://reader033.fdocuments.in/reader033/viewer/2022050617/547fb076b379593f2b8b58d6/html5/thumbnails/26.jpg)
OBJECTIVE
1. To easily identify critical patient issues /
Concerns in the progress notes.
2. To facilitate Communication among all Disciplines.
![Page 27: Focus Charting 2](https://reader033.fdocuments.in/reader033/viewer/2022050617/547fb076b379593f2b8b58d6/html5/thumbnails/27.jpg)
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 patient’s concern
and/or plan of care.Ex. Health teaching per shift
![Page 28: Focus Charting 2](https://reader033.fdocuments.in/reader033/viewer/2022050617/547fb076b379593f2b8b58d6/html5/thumbnails/28.jpg)
GENERAL GUIDELINES ….
4. Document patient’s status on admission, for every transfer to/from another unit or discharge.
5. Follow the do’s of documentation.6. For eight hours shift, use blue or black
ink for morning and afternoon shifts, red ink for night shift.
![Page 29: Focus Charting 2](https://reader033.fdocuments.in/reader033/viewer/2022050617/547fb076b379593f2b8b58d6/html5/thumbnails/29.jpg)
Specific Guidelines
1. Begin with comprehensive assessment of the patients using inspection, palpation, percussion and auscultation (IPPA).
2. 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.
![Page 30: Focus Charting 2](https://reader033.fdocuments.in/reader033/viewer/2022050617/547fb076b379593f2b8b58d6/html5/thumbnails/30.jpg)
Specific Guidelines….
3. Establish a focus of care, to be addressed in the Progress notes.
![Page 31: Focus Charting 2](https://reader033.fdocuments.in/reader033/viewer/2022050617/547fb076b379593f2b8b58d6/html5/thumbnails/31.jpg)
FOCUS
A 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
![Page 32: Focus Charting 2](https://reader033.fdocuments.in/reader033/viewer/2022050617/547fb076b379593f2b8b58d6/html5/thumbnails/32.jpg)
FOCUS
An acute change in an individuals conditionex.Respiratory distress, seizure
A significant event in an individuals care ex.
Change in diet catheterizationA key word or phrase indicating
compliance with standard care or policy.
Ex. teaching plan
![Page 33: Focus Charting 2](https://reader033.fdocuments.in/reader033/viewer/2022050617/547fb076b379593f2b8b58d6/html5/thumbnails/33.jpg)
FOCUS…. The focus might be patient strength,
problem, or need. Topics that may appear in the focus Column include patient’s 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.
![Page 34: Focus Charting 2](https://reader033.fdocuments.in/reader033/viewer/2022050617/547fb076b379593f2b8b58d6/html5/thumbnails/34.jpg)
FOCUS CHARTING USES NARRATIVE DOCUMENTATION
(DAR) DATA – SUBJECTIVE OR OBJECTIVE THAT
SUPPORTS THE FOCUS (CONCERN)
ACTION – NURSING INTERVENTION
RESPONSE – PT RESPONSE TO INTERVENTION
![Page 35: Focus Charting 2](https://reader033.fdocuments.in/reader033/viewer/2022050617/547fb076b379593f2b8b58d6/html5/thumbnails/35.jpg)
FOCUS….
The narrative portion of focus charting includes
Data, Action and Response ( D A R ).
![Page 36: Focus Charting 2](https://reader033.fdocuments.in/reader033/viewer/2022050617/547fb076b379593f2b8b58d6/html5/thumbnails/36.jpg)
Data ……
- Is the subjective and/or objective information supporting the stated focus or describing the observation at the time of a significant event.
![Page 37: Focus Charting 2](https://reader033.fdocuments.in/reader033/viewer/2022050617/547fb076b379593f2b8b58d6/html5/thumbnails/37.jpg)
Action….
- Describes the nursing interventions (independent, basic and perspective) past, present, future.
![Page 38: Focus Charting 2](https://reader033.fdocuments.in/reader033/viewer/2022050617/547fb076b379593f2b8b58d6/html5/thumbnails/38.jpg)
Response….
- Describes the patient outcome/response to interventions or describes how the care plan goals have been attained.
![Page 39: Focus Charting 2](https://reader033.fdocuments.in/reader033/viewer/2022050617/547fb076b379593f2b8b58d6/html5/thumbnails/39.jpg)
Focus Note
1. Is necessary to describe a patient’s 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
![Page 40: Focus Charting 2](https://reader033.fdocuments.in/reader033/viewer/2022050617/547fb076b379593f2b8b58d6/html5/thumbnails/40.jpg)
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 patient’s condition- when there has been an event of new patient condition.
Ex. - Respiratory distress- Seizure
![Page 41: Focus Charting 2](https://reader033.fdocuments.in/reader033/viewer/2022050617/547fb076b379593f2b8b58d6/html5/thumbnails/41.jpg)
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.
![Page 42: Focus Charting 2](https://reader033.fdocuments.in/reader033/viewer/2022050617/547fb076b379593f2b8b58d6/html5/thumbnails/42.jpg)
Ex.
• Admission • Pre-(specify procedure) assessment • Post-(specify procedure) assessment • Pre-transfer assessment • Discharge planning • Discharge status• Transfusion RBC• Begin thrombolytic therapy• PRN medication required
![Page 43: Focus Charting 2](https://reader033.fdocuments.in/reader033/viewer/2022050617/547fb076b379593f2b8b58d6/html5/thumbnails/43.jpg)
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.
![Page 44: Focus Charting 2](https://reader033.fdocuments.in/reader033/viewer/2022050617/547fb076b379593f2b8b58d6/html5/thumbnails/44.jpg)
To describe all specific patient/family teaching.
This is in compliance with a standard of care.
![Page 45: Focus Charting 2](https://reader033.fdocuments.in/reader033/viewer/2022050617/547fb076b379593f2b8b58d6/html5/thumbnails/45.jpg)
ex. - Social service/financial assistance
Dietitian/instruct low fat diet Physical therapy/crutch walking
![Page 46: Focus Charting 2](https://reader033.fdocuments.in/reader033/viewer/2022050617/547fb076b379593f2b8b58d6/html5/thumbnails/46.jpg)
To best describe patient’s condition in relation to medical diagnosis
When the patient’s focus is the pathophysiology rather than patient’s response to the problem.
This happens most frequently in highly technical areas such as critical care.
![Page 47: Focus Charting 2](https://reader033.fdocuments.in/reader033/viewer/2022050617/547fb076b379593f2b8b58d6/html5/thumbnails/47.jpg)
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.
![Page 48: Focus Charting 2](https://reader033.fdocuments.in/reader033/viewer/2022050617/547fb076b379593f2b8b58d6/html5/thumbnails/48.jpg)
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.
![Page 49: Focus Charting 2](https://reader033.fdocuments.in/reader033/viewer/2022050617/547fb076b379593f2b8b58d6/html5/thumbnails/49.jpg)
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.
![Page 50: Focus Charting 2](https://reader033.fdocuments.in/reader033/viewer/2022050617/547fb076b379593f2b8b58d6/html5/thumbnails/50.jpg)
DATA and ACTION are responded at one hour and RESPONSE is not added until later, when the patient outcome is evident.
![Page 51: Focus Charting 2](https://reader033.fdocuments.in/reader033/viewer/2022050617/547fb076b379593f2b8b58d6/html5/thumbnails/51.jpg)
Response is used alone to indicate that a care plan goal has been accomplished.
![Page 52: Focus Charting 2](https://reader033.fdocuments.in/reader033/viewer/2022050617/547fb076b379593f2b8b58d6/html5/thumbnails/52.jpg)
DATE/TIME
FOCUS
DATA, ACTION, RESPONSE
03/08/08 7-3pm10 am
12 noon
1:05 pm
Chest pain
D:” Sumasakit ang dibdib ko,” Midclavicular line pain of 4 on scale of 5
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……………
![Page 53: Focus Charting 2](https://reader033.fdocuments.in/reader033/viewer/2022050617/547fb076b379593f2b8b58d6/html5/thumbnails/53.jpg)
DATE / TIME09/15/087-3 pm
10 AM
FOCUS
HealthTeaching:DressingChange
DATA, ACTION, RESPONSE
R: Patient demonstrated, he is able to change his
own abdominal dressing using
aseptic technique.
Bea Alonzo, RN
![Page 54: Focus Charting 2](https://reader033.fdocuments.in/reader033/viewer/2022050617/547fb076b379593f2b8b58d6/html5/thumbnails/54.jpg)
Ex.
DATE / TIME 19/15/087-3 pm10 AM
FOCUS
Post Transfer Assessment
DATE, ACTION, RESPONSED: 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. Bea Alonzo RN.
![Page 55: Focus Charting 2](https://reader033.fdocuments.in/reader033/viewer/2022050617/547fb076b379593f2b8b58d6/html5/thumbnails/55.jpg)
ACTION AND RESPONSEex.
DATE / TIME09/15/087-3pm9 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.)
![Page 56: Focus Charting 2](https://reader033.fdocuments.in/reader033/viewer/2022050617/547fb076b379593f2b8b58d6/html5/thumbnails/56.jpg)
Cont……
9:15 am
9:30 am
A: Gastrostomy bag lowered
R: “ I feel better now.” Approximately 200 cc gastric fluid; returned as much flatus
A: Keep gastrostomy bag below body level.Bea Alonzo, RN
![Page 57: Focus Charting 2](https://reader033.fdocuments.in/reader033/viewer/2022050617/547fb076b379593f2b8b58d6/html5/thumbnails/57.jpg)
Begin the note with ACTION when the patient’s interaction begins with intervention or when including data would be unnecessary repetition.DATE / TIME09/15/08
9 AM
FOCUSHealth
TeachingDigoxin
DATA, ACTION, RESPONSEA: 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”,
Bea Alonzo, RN
![Page 58: Focus Charting 2](https://reader033.fdocuments.in/reader033/viewer/2022050617/547fb076b379593f2b8b58d6/html5/thumbnails/58.jpg)
DATE / TIMEO9/15/08
9 AM
9:10 am
9:20 AM
FOCUS
Pain at IV site
DATA, ACTION, RESPONSE
D -” masakit and pinaglagyan ng
dextrose ko”, Check IV site, found
beginning 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 dextrose ko”.
![Page 59: Focus Charting 2](https://reader033.fdocuments.in/reader033/viewer/2022050617/547fb076b379593f2b8b58d6/html5/thumbnails/59.jpg)
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 as an acute condition, a potential problem, a treatment procedure or a patient behavior.
![Page 60: Focus Charting 2](https://reader033.fdocuments.in/reader033/viewer/2022050617/547fb076b379593f2b8b58d6/html5/thumbnails/60.jpg)
Again …..
The quality of records maintained by nurses is a reflection of the quality of care provided by them to patients/clients.
![Page 61: Focus Charting 2](https://reader033.fdocuments.in/reader033/viewer/2022050617/547fb076b379593f2b8b58d6/html5/thumbnails/61.jpg)
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.
![Page 62: Focus Charting 2](https://reader033.fdocuments.in/reader033/viewer/2022050617/547fb076b379593f2b8b58d6/html5/thumbnails/62.jpg)
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.
![Page 63: Focus Charting 2](https://reader033.fdocuments.in/reader033/viewer/2022050617/547fb076b379593f2b8b58d6/html5/thumbnails/63.jpg)
Case 3
A patient is transferred to the medical-surgical ward for congestive heart failure. Shortly after admission, the nurse assesses his condition. He is dyspneic and slightly cyanotic.
![Page 64: Focus Charting 2](https://reader033.fdocuments.in/reader033/viewer/2022050617/547fb076b379593f2b8b58d6/html5/thumbnails/64.jpg)
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.
![Page 65: Focus Charting 2](https://reader033.fdocuments.in/reader033/viewer/2022050617/547fb076b379593f2b8b58d6/html5/thumbnails/65.jpg)
Thank you and God bless !!!
![Page 66: Focus Charting 2](https://reader033.fdocuments.in/reader033/viewer/2022050617/547fb076b379593f2b8b58d6/html5/thumbnails/66.jpg)
Elvira Cachuela- Atuel, RN, MAN, US-RN
![Page 67: Focus Charting 2](https://reader033.fdocuments.in/reader033/viewer/2022050617/547fb076b379593f2b8b58d6/html5/thumbnails/67.jpg)
Workshop
Group 1A 17 year old boy is admitted to the
male ward from ER with difficulty of breathing; HR of 102 bpm; temp. 36.5; RR 16; with tentative diagnosis of Chronic bronchitis
![Page 68: Focus Charting 2](https://reader033.fdocuments.in/reader033/viewer/2022050617/547fb076b379593f2b8b58d6/html5/thumbnails/68.jpg)
Group 2
An 8 month old baby with AGE; poor sucking; sunken eyes and poor skin turgor; still with bouts of diarrhea 3 times within 1 hour in the ward.
![Page 69: Focus Charting 2](https://reader033.fdocuments.in/reader033/viewer/2022050617/547fb076b379593f2b8b58d6/html5/thumbnails/69.jpg)
Group 3
A 75 year old male is was admitted with complaint of SOB, now complains of chest pain two days after admission; has previous history of MI; pain scale is 6 of 10