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The Focus Charting System is the
accepted documentation system at
Windsor Regional Hospital.
Focus Charting
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Flexible enough to adapt to any clinical practice
setting and promotes interdisciplinary
documentation
Centers on the nursing process, includingassessment, planning, implementation and
evaluation Information is easy to find because data is
organized by the focus. It promotes communication between all care
team members.
Advantages of FocusCharting
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Encourages regular documentation of patient
responses to care Helps organize document so that it is concise
and precise Can be easily adapted to computer based
documentation systems
Advantages of FocusCharting
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The Focus: It describes the focus of actions
DAR format: Is the structure used to document
patient assessment, care interventions or actions and
patient responses to the actions or care
Focus Charting Combines
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Focus Lists
Progress Notes
Flow Sheets Care Plans
The Focus System Uses:
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A focus may also be written in the format of a nursing diagnosis
Refers To Example
A patient behaviour Inability to ambulate
An acute change in the patients conditionLoss of consciousness
or increase in blood pressure
A significant event in the patients therapy Surgery
A special patient need Discharge planning need
Hypotension, or chest painA sign or symptom
Developing the Focus
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A FOCUS LIST sheet is used as an index or quick reference
for what you will find in the progress notes. All disciplinesshould record on the focus list
The focus is numbered in order
that they are listed
Document the focus
The date the focus is identified
is indicated in the active
column
The dates are entered if the
focus is resolved or resinstated
The discipline entering the focus
should identify themselves.
1
2
Inability to
ambulateChest pain Nursing
Nursing, PT11/12/01
11/12/01
The Focus List
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Focus Lists must be regularly updated
and expanded as the patients
condition changesAt discharge, focus list needs to be
checked to ensure that all the
foci have been addressed and / or
resolved.
The Focus List
Additional Information about the Focus ListAdditional Information about the Focus List
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All disciplines should have a
plan of care.
Care Plans are included either
as a standard nursing
care plan
or as an entry in the
progress notes
under the A. Standardized care plans should
be activated with the patient
and/or significant othersin ut in order to make it
Once a focus has been identified, a plan of care needsOnce a focus has been identified, a plan of care needsto be documented.to be documented.
The Use of Care Plans
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There are numerous pre-printedflow sheets available at WRH
These are helpful in accurately
and concisely documenting
routine and frequently collected
data Use flow sheets whenever it is
logical and helpful to do so. For
example: Any documentation
which is required on a regular
basis by hospital policy or
standard. Any nursing care activity which
is provided on a regular basis
i.e. activities of daily living
Flow Sheets
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Examples of Flow sheets are:Examples of Flow sheets are: vital signs record, medication record, intake and output,
post op flow sheet, wound assessment record
Flow Sheets
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All flow sheets must becorrectly dated and
must contain the
patients
name on both sides.
All entries on the flowsheets must be initialed
(no use of check marks)
by the person who
assesses or provides
the care and must have
initials with full signature
on a master copy. Any variances from
normal should be
recorded in DAR format
01/12/02
JSJSJSJS
Flow Sheets
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Dos Charting on the flow sheets should be
done as the care is delivered
or patient data observed
Develop assessment parameters that
have meaning to everyone for example:Check abd incision q2h for drainage,
redness, tenderness versus check
incision
Make the flow sheets reflect the care
needs of the patient
Be concise
Analysis of the trends in the patient data
to assess if there are changes in the
patients condition
Write legibly
Dont leave blanks
Dont squeeze data into
spaces provided. If not
adequate space it isnecessary to progress
note
Double document in
various parts of the
charting system
Donts
Flow Sheets
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Are Used to: Provide detail to data in a flow sheet. Document patient response to care.
Record an unusual or unexpected event.record changes in patient condition and
notification to the MD Describe the status of the patient at the time of
admission, transfer from one nursing unit toanother, or at the time of discharge.
Progress Notes
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When writing progress notes you shouldinclude information about:
Progress Notes
The details about the patients condition
(assessment data)
The interventions or nursing actionsimplemented and their effectiveness
The patients response to care
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Notes are chronologicallyentered. The date and
time is documented in the
columns provided. The
time and date you are
actually writing the note is
used.
The service or discipline
writing the note is
recorded
When starting a note the focus is
documented first
In focus charting the
structure of the progress
note that follows the focus
uses a DAR outline: Data,
Action Response
Nov. 12/01 1400 O.T. #1 -Swollen painful left hand.----------------
D - Assessment done as per referral-----------
Left hand swollen. Digits in extension.---Painful to passive ranging.---------------
A - Discussed splint use and benefits with Pt.
Splint molded. On-off schedule developed.
R - Pt. concerned splint will be painful------
------------------------------K. Smith O.T.
How to Complete a Progress Note
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Is an acronym
Data - subjective & objective patient assessment data thatsupports the Focus Statement or describes observations of a
significant event
Action - immediate or future actions or plans of action
or care based on the evaluation of assessment data
Response - the patient response to the action taken.
How to Complete a Progress Note
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The Response may not need to be immediately charted. There may
not be an immediate response, therefore, only Data and Action may
be charted
Eventually, there should be a Response entered to that action taken
Progress notes must have a
signature after each entry
There may be more than one
focus that requires charting at
one time
D a t e T i m eJ u n e2 2 2 22 2 2 2 N r s g . W o u n d D r e s s i n g
1 1 1 1
D - M o d e r a t e a m o u n t o f p u r u l e n t , f o u li n c i s i o n n o t e d . S u t u r e l i n e r e d a n d s w o2 2 2c o m p l a i n i n g o f p a i n a t t h e s i t e . - - - - - - - - - -A - D r . B . J o n e s n o t i f i e d a n d i n f o r m e dr e c e i v e d . A n a l g e s i c a n d a n t i p y r e t i c g i vt a k e n a n d s e n t t o L a b . W o u n d c l e a n s ed r y d r s g . A p p l i e d . - - - - - - - - - - - - - - - - - - - - - - - - - - - -- - - - - - - - - - - - - - - - - - - - - -R - T . P a t i e n t s t a t e s i n c i s i o n a l p a i n i1 1a n d i n t a c t , n o d i s c h a r g e n o t e d . A n t i b i o- - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - -
Joan Smith R.N.
Joan Smith R.N.
Progress Notes
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Write patient progress notes only when necessary.The goal is to minimize duplication of information and
to save time.
Date Time22 June 98 1500
Nrsg.#1 pneumonia
D - pt. c/o of chest pain on inspiration, fatigue.T-39.5 at 1515, wheezy breath sounds, productivecough for purulent tenacious sputum. IV infusing.A - 02 at 3 litres, chest x-ray this am, sputumfor C&S referral for chest physio. Tylenol ii for
elevated temp at 1520. Fluids encouraged.R-T @1620 - 38---------------------Amy Nurse, RPN
Progress Notes
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Objective Precise
Specific Thorough
Progress notes can be improved bychoosing language which is:
Focus Charting Dos and Donts
Inconsistencies in documentation can leave you and the health care
facility open to accusations of incompetence.A medical record containing inconsistencies can be difficult to defend
in court. DO NOT use words like confused, uncooperative and depressed.
These words may be interpreted in different ways and are not specific
in accurately describing the patient
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Eats poorly
Patient confused
Uncooperative
Patient complaining of pain
Good day
Diuresing well
Walking ad lib
Ate 1/2 the meal and drank 80 ml fluid
Patient unable to recognize family
Refuses to assist with am care
Complaining of constant, sharp RUQabd. Pain
Patient states has been pain free
without medication and still able to
complete activities of daily living
Lasix 10 mg IV at 1430 resulted in
1000 ml of clear, yellow urine.
Walks around the unit, up to the elevator
and back to room without any discomfort
Focus Charting Dos and Donts
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Be FactualBe Factual
Be SpecificBe Specific
Be PreciseBe Precise
Be ThoroughBe Thorough
Be FactualBe Factual
Be SpecificBe Specific
Be PreciseBe Precise
Be ThoroughBe Thorough
In Summary
Avoid Summarizing or using Value
Judgements