Focus Charting (FDAR)

Focus Charting (FDAR)

• 1.
  Focus Charting
• 2.
  Focus charting describesthe 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 isnecessary  ° 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 FocusCharting: 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.
   ° ACTIONand 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.