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
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
4. • 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
5. • 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
6. 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
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
notes
• Focus notes – written on the second column
• Data, Action and Response – third column
8. 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
9. 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
10. 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)
11. 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
12. 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
13. SPECIFIC GUIDELINES
• Response describes the patient
outcome/response to the
interventions or describes how the
care plan goals have been attained
14. • 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
15. • 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
16. • 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)
17. • 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
18. • 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
19. • 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
20. • 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
21. • 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)
22. • 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
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
03/08/14
Chest pain D: “sumasakit ang dibdib ko”.
10 am
Midclavicular line, 4/10 on
pain scale
A: Medicated with Isordil 5mg tab
SL
L. Dela Cruz, RN
03/08/14
12 pm
Chest Pain R: Resting in bed. “Nabawasan na
ang sakit ng dibdib ko”. Pain
Scale 2/10.
L. Dela Cruz,RN
25. Response is used alone to indicate if a care of plan
goal has been accomplished
Date/ Time Focus Data, Action and Response
03/15/14
10 am
Health
Teaching:
Dressing
Change
R: Patient demonstrates that he is
able to change his own
abdominal dressing using
aseptic technique
C. Ballesteros, RN
26. 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
03/18/14
2pm
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
27.
28. 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
29. 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
30. 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
31. 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
