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focus charting

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2 views2 pages

focus charting

Uploaded by

Egin Synco
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
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Title: Guidelines for the Use of the Focus Charting

Outcome:

The nurse shall complete documentation of the individual's progress toward


and achievement of outcomes utilizing focus charting. The attached form
may be used or facilities may use existing forms as long as the focus method
of documentation is used. (See Attachment A)

Nature:

1. The focus charting form is part of the permanent medical record.


2. Client, name, DMR number in left upper corner.
3. The form will be completed in blue or black ink.
4. Correct a mistaken entry by placing a single line through the entry and
write "omit" above it and initial.

Definitions:

Focus Charting - is a method for organizing health information in the


individual's record. It is a systematic approach to documentation, using
nursing terminology to describe individual's health status and nursing action.

Focus

a key word or diagnostic category from a nursing diagnosis or


collaborative problem on the plan of care (action plan),
i.e. skin integrity, coping, activity tolerance, self care deficit
a current individual concern or behavior,
i.e. nausea, chest pain, pre-op teaching, hospital admission
a sign or symptom of (possible) importance to the nursing and/or
medical diagnosis or treatment plan,
i.e. fever, constipation, hypertension, incontinence, lethargy
 an acute change in an individual's condition,
i.e. respiratory distress, seizure, fever, discomfort
a significant event in an individual's care,
i.e. begin treatment regimen (oxygen), change in diet,
catheterization
a key word or phrase indicating compliance with a standard of care or
agency policy,
i.e. self medication teaching plan, transition
Components of a Focus Note

Data: Subjective and/or objective information supporting the stated focus or


describing observations at the time of significant events.
Action: Nursing interventions performed, planned to be performed, and/or
protocols and procedures initiated.
Response Description of individual's response to medical and/or nursing care.
: Statement that the Action Plan of Care outcomes have been attained or
are progressing toward attainment.

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