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Focus Charting

F-DAR

Nursing as a profession
Assumes accountability for nursing action

Nursing accountability
- Apply concepts learned for nursing action geared towards patients needs

Identifying patients needs


Leads to well-planned, individualized, effective nursing care

Remember
DOCUMENTING is PATIENT CARE The GOLDEN RULE:
WHAT is written was done, and what was done must be written.

Purposes of Nursing Records


communication tool for healthcare team Legal document Financial billing Education Assessment Research Auditing and monitoring
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FOCUS CHARTING
Identifies patient-centered concerns, issues and problems

Focus ChartingDAR
DATA
Subjective and objective data that supports the focus Assessment phase of the nursing process

ACTION
Interventions, such as medication, treatment, calls to the physician, and patient teaching. Planning and implementation phase of the nursing process

RESPONSE
Patients response to your interventions Evaluation phase of the nursing process

What can be your FOCUS?


1. A patients problem/focus or concern from the nursing care plan-when the purpose of the note is to evaluate progress toward the defined patient outcome. Example:
skin integrity coping activity intolerance self-care deficit physical mobility tissue perfusion airway clearance

Date/Time

Focus

DAR charting
D: coarse crackles on right upper lung. unable to bring up phlegm. A: placed on moderate high back rest. Nasotracheal suctioning done. Oxygenation at 2LPM as ordered via nasal cannula. R: suctioned thick yellowish mucous plenty in amount. Able to sleep after. A San Antonio RN

August 16, 2010 1000H F: Airway clearance

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What can be your focus?


2. A new finding to document a new sign and symptom or behavior which is the current focus of care. Example:
constipation Diarrhea Wheezes Hematoma Chest pain Nausea bleeding
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Date/time
August 16, 2010 0700H

Focus chest pain

DAR charting D: patient complained of mid-sternal pain radiating to the left, stabbing with a pain scale of 7/10. A: hooked to cardiac monitor. Monitored v/s. oxygenation at 4LPM via nasal cannula. Referred to MOD. Medicated with Morphine SO4 10 mg IV as ordered. R: rested in bed, v/s taken, BP 130/90 HR 78/min, regular rate and rhythm. Patient stated pain decreased to rating of 3/10. A San Antonio RN.

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What can be your focus?


An acute change in a patients condition. Example:
Respiratory distress Seizure Fever/hyperthermia Discomfort

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What can be your focus?


A significant event or unusual episode in patient care when:
a. Responsibility for patient care changes from one department to another

Example:
Admission Pre-(specify procedure) assessment Post -(specify procedure) assessment Pre and post transfer assessment Code blue or code red
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Date/time

Focus

DAR charting D: 56 y/o female admitted from ER per wheelchair with an IVF of D5LR on right metacarpal vein using g22 abbocath regulated to 20gtts/min infusing well. A: assisted comfortably in bed ,nursing health history taken. Oriented to hospital policies. Initial v/s taken. R: patient responded positively to orientation, expressed desire to be seen by her attending physician. A San Antonio RN

August 16, 2010 0800H F:admission

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What can be your focus?


b. A significant treatment/ intervention took place Example:
Begin treatment regimen (begin thrombolytic therapy) Begin oxygen therapy Blood transfusion Change in diet Catheterization IV insertion Intubation
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Date/time August 16, 2010 0900H

focus

DAR charting

Blood transfusion D: bloody CT drain of 100ml/hr, patient is pale looking, hemoglobin level taken 7 mg/dl. A:blood transfusion of 1 unit PRBC SN NVBSP201000 started at 1000H to run for 4 hours. Initial VS taken prior to transfusion.(please see blood transfusion sheet). Observed for protocol on blood transfusion. R: BT ended at1400H. VS monitored throughout the procedure, stable. No untoward signs and symptoms noted. A San Antonio RN

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What can be your focus?


An activity or treatment that was not carried out or performed, or clients refusal to allow treatment or take medication. Example:
Refusal of medication Refusal of iv insertion Refusal to raise side rails Loss of appetite Wound drainage
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Date/time August 16, 2010 1100H

Focus Refusal to raise side rails

DAR charting D: informed the patient the need to raise side rails up, however, patient verbalized dont put me inside this cage, I will not fall anyway
A:explained that its a hospital protocol to have bed side rails up especially at night time for safety . However, the patient insisted theres no need because she will not fall. Notified MD and supervisor. R: agreed to sign the waiver for refusal. Waiver attached to chart, endorsed to incoming shift for continuity of care.
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What can be your focus?


All specifics regarding patient and family teachingshealth teachings or other relevant instructions given to the patient. Example:
Diet restrictions Feeding Medication (specify) Discharge instructions
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Date/time

Focus

DAR charting
D: patient queried about the new medicine he is taking that his doctor told him about. A: informed patient about Lanoxin which he is supposed to take 2x a day, and that it makes the heart pump better. Explained the need to take his full minute heart rate before taking the medicine. R: expressed understanding by return demo on how he should take the heart rate by using the radial pulse. A San Antonio RN

August 16, 2010 1200H F: Health teaching: medication (Lanoxin)

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What can be your focus?


Members of the health team who made a note or entry in the patients chartchart what you feel is important data from visits made by physician especially referrals and from other members of the health care team such as:
Dietitian Social worker Chaplain Physical rehabilitation and others

Example:
Social service-financial assistance Dietitian-diet instructions Physical rehabilitation- instructions on crutch walking

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Date/time

Focus

DAR charting
D:MD ordered for low fat diet . A:Informed dietitian regarding new order for diet. Requested to conduct counseling/instructions regarding dietary regimen. R: dietitian conducted dietary counseling at the bedside with the presence of wife. A San Antonio RN

August 16, 2010 1300H F: Dietitian-instruction on low fat diet

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What can be your focus?


Patients condition related to his/her medical diagnosisa sign or symptom which is of (possible) importance to the nursing and or medical diagnosis and treatment plan. Example:
Hyperkalemia Hypertension Arrhythmia Hypoglycemia Incontinence Retention
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Date/time

Focus

DAR charting
D: bigeminy noted in scope. CR 65 to 70bpm BP 110/70mmHg A: obtained tracing and referred to MD. continuous cardiac rhythm monitoring. Monitored for bp and urine output. Standby Lidocaine at the bedside as ordered. Blood for serum determination sent to laboratory. R: still with periodic episodes of bigeminy but bp remains stable. Patient rested, no untoward manifestations noted. A San Antonio RN

August 16,2010 1400H F: Arrhythmiabigeminy

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Remember Data and action are recorded at one hour Response is not added until later, when the patients outcome is evident.

Date/time
August 16, 2010 1500H

Focus
F: fever

DAR charting
D: temperature taken via axillacentigrade. Flushed skin, warm to touch. 39

A: cooling measures provided-sponge bath rendered, changed with lighter clothing, increase fluid intake encouraged. A San Antonio RN 1700H fever R: latest temperature taken per axilla-37.6 centigrade. A San Antonio RN

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Remember Response is used alone to indicate that a care plan goal has been accomplished

Date/time August 16, 2010 1800H

Focus Health teaching: taking of pulse

DAR charting R: patient demonstrated he is able to take his pulse by using the radial pulse. Checked with the patient accuracy of pulse rate taken. A San Antonio RN

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Remember Data is used alone when the purpose of the note is to document assessment finding and there is no flow sheet/checklist for that purpose.

Date/time August 16, 2010 2000H

Focus Post-transfer assessment

DAR charting D: received from RR via stretcher, awake and alert, vital signs stable. IV on right arm patent. Foley catheter in place with clear yellow urine, dressing on RLQ clean and dry, moving all extremities voluntarily. A San Antonio RN

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Remember Begin the note with ACTION when the patients interaction begins with intervention or when including data would be unnecessary repetition.

Date/time

Focus

DAR charting

August 16 2010 2100H

Health teaching: Digoxin

A: patient instructed on the actions and side effects of Digoxin. Given Digoxin information guide. Discussed when he would call the physician about the medicine.
R: returned demonstration of radial pulse. Patient expressed: I understand the purpose of the medication. A San Antonio RN

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The DOs of Charting


Do check the name and identifying number on the patients chart and on each page Do read what other providers have written before charting your care Do time and date all entries Do chart legibly

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The DOs of Charting


Avoid errors in grammar and spelling Do keep all patient data strictly confidential Do be factual, specific and complete
Use direct patient quotes when appropriate Record what you see, hear, smell, feel, measure and count

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The DOs of Charting


Do sign in your name immediately after the last word of your entry Do use only commonly used or approved abbreviations and symbols Do document outcomes of nursing intervention to show effectiveness of care Do document discharge instructions including:
Referrals to other health agencies and community providers Any patient teaching that was done.
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The Dos of Charting


Do write entries in order of consecutive shifts and days. Document the date and time for each entry you write. Do document the patients refusal of treatment and your patient teaching about the need for treatment and possible consequences of refusal.

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The Dos of Charting


Do record each phone call to or from a physician, including exact time, message and response Do chart as soon as possible after giving care Do chart precautions or preventive measure used

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Pitfalls of Documentation
Writing legibly could lead to errors, misunderstanding Leaving blank lines: someone could insert info at a later date Altering someone elses notes Back dating records

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Pitfalls of Documentation
Using immeasurable terms: each entry should reflect clarity and brevity (use as few words as possible) Failing to document communication with other healthcare members regarding client care: Remember: IF IT WAS NOT DOCUMENTED, IT WAS NOT DONE

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Pitfalls of Documentation
Correcting errors incorrectly: only draw a single line through error and write error above it with nurses initial Inserting info between lines : big NO Documenting for someone else: each nurse should only document their own care and observations Expressing opinions
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Pointers To remember
If you remember an important point after youve completed Your documentation, chart the information with a notation that its a late entry Include the date and time of the late entry If the information on a form such as the Flow sheet or Kardex doesnt apply to your client, write NA (not applicable) on the space provided
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Points to remember
When documentation continues from one page to another, sign the bottom of the first page, write the date, time and continued from previous page Include the following information when documenting nursing procedures:
What procedure? When? Where? Who performed? Patients response to the procedure? (adverse reaction to the procedure, if any)
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Questions?
What if my patient has no problem? What if my patient is for home already and just cannot settle yet the bill?

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GUIDELINES
*DOH HNSA Manual

Information from all categories (DAR) should be used only as they are relevant. All appropriate information should be included to ensure complete documentation. DA are responded at 1 hour; R is not added until later when the patient outcome is evident.
DATE/TIME 06/07/11 10AM 12 Noon FOCUS Chest Pain DATA, ACTION, RESPONSE D: Midclavicular pain of 4 on scale of 10. A: Medicated with Isordil 5mg SL. M. A. Ojos, RN R: Resting in bed. Rated pain at 2. M. A. Ojos, RN
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Chest Pain

GUIDELINES
*DOH HNSA Manual DA are responded at 1 hour; R is not added until later when the patient outcome is evident.
DATE/TIME
06/02/11 10 AM

FOCUS
Nursing Wound Dressing

DATA, ACTION, RESPONSE


D: Moderate amount of purulent, foul smelling drainage from abdominal incision noted. Suture line red and swollen and warm to touch T= 39.5. Complaining of pain at the site. A: Dr. B. Jones notified and informed of patients incisional status. Orders received. Analgesic and antipyretic given as ordered. C&S of wound taken and sent to Lab. Wound cleansed with antibacterial solution. Dry dressing applied. J. Lo, RN R: Temp. = 38. Patient states incisional pain improving. Dressing dry and intact. No discharge noted. J. Lo, RN
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12:30 PM

GUIDELINES
*DOH HNSA Manual

Response is used alone to indicate a care plan goal has been accomplished.
DATE/TIME FOCUS DATA, ACTION, RESPONSE

06/01/11 9AM

Health Teaching: Dressing change

R: Demonstrated change of his own abdominal dressing using aseptic technique. M. A. Ojos, RN

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GUIDELINES
*DOH HNSA Manual

Data is used when the purpose of the note is to document assessment finding and there is no flowsheet/checklist for that purpose.
DATE/TIME FOCUS DATA, ACTION, RESPONSE

12/18/10 2:20 PM

Post Transfer Assessment

D: Received from the RR via stretcher awake and alert, VS stable, IV at right forearm patent, Foley cath in place draining to clear yellow urine, dressing on RLQ clean & dry, able to move all extremities voluntarily. Minimal incisional pain rated at 3. M. A. Ojos, RN

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GUIDELINES
*DOH HNSA Manual

A & R are repeated without additional data to show the sequence of decision making based on evaluating patient response to initial intervention.
DATE/TIME FOCUS DATA, ACTION, RESPONSE

06/04/11 10 PM Nausea

D: I feel like my stomach is filling up with pressure again. Im nauseated. Abdomen soft, gastrostomy bag at body level. Rare bowel sounds. A: Gastrostomy bag lowered. R: I feel better now. Approx. 200mL golden fluid in gastrostomy bag. A: Keep gastrostomy bag at body level. Monitor how long bag is tolerated at body level. Monitor abdominal status. Document time and amount of drainage and discomfort. Instructed to call nurse when he is uncomfortable. R: I understand plan. M. A. Ojos, RN
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GUIDELINES
*DOH HNSA Manual

Start the note with ACTION when patients interaction begins with intervention or when including date would be unnecessary repetition.
DATE/TIME FOCUS DATA, ACTION, RESPONSE

04/15/11 2:20 PM Health Teaching: A: Informed on the actions and side Digoxin effects of digoxin. Given digoxin information card. Discussed when he would call the physician about the medicine. R: Return demonstration of radial pulse checking. M. A. Ojos, RN
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