FOCUS CHARTING

PURPOSE
To provide the multidisciplinary team with a structured note format for documenting The patients health and well being The care provided The effect of the care and the continuity of the care.

 Focus charting brings the focus of care back to the patient and patient concerns.

Documentation
Will reflect : Collection and analysis of Data Actions taken Evaluation of outcomes by supporting critical thinking by the Health Care Professional in the clinical decision making process.

Documentation Forms

Documentation Forms
Chart Documentation Signature Sheet NB 192 Clinical Record NB 162 300 McLaren Appropriate NBGH Flowsheets
Dictaphone/Tape Record

Procedure
Ensure the imprint of the addressograph on the Clinical Record corresponds to the correct patient.
Document on appropriate forms approved by the North Bay General Hospital. Document the date and time of the care, or the event, in the designated columns on the Clinical Record.

Procedure
Black permanent ink is to be used when charting Each Health Care Professional who documents in writing in the patients record must sign and initial on the Chart Documentation Signature Sheet All documentation will be accompanied by appropriate identification of the caregiver making the entry onto the patient chart.

Documentation Principles
Documentation must be able to determine: When an event happened What happened To whom it happened By whom it happened Why it happened The result of what happened

Documentation Principles
Maintain confidentiality of all patient information. Documentation will be retrievable Documentation is to be neat, legible, and non-erasable. Records must be an accurate, true and honest account of what occurred and when it occurred.

Documentation Principles
Documentation contains meaningful information, and avoids meaningless phrases, such as, good night, up and about, or usual day. Information documented must be relevant . Provides current, clear, complete, concise, concrete, documentation of the patients status with the least possible duplication of information.

Documentation Principles
Documentation must be reflective of observations not unfounded conclusions. Avoid statements such as, appears to and seems to when describing observations. Documentation must reflect the assessment, planning, implementation and evaluation of patient care.

Documentation Principles
Documentation will contain all clinical observations, actions taken by the health care providers, all treatments, as well as, the patients response to the care provided.

Documentation Principles
Document in a timely manner, during or as soon as possible, after the delivery of care. Never chart before the delivery of care.

Chart in chronological order, documenting entries in sequence of events. Do not document in blocks of time i.e. August 16, 2006 1200 1600 hours

Forgotten or Late Entries

Forgotten or late entries are to be documented on the next available space within the Clinical Record.

Forgotten or Late Entries

Documentation must clearly state when the care was provided or when an event occurred, and when the documentation of the care/event occurred to be reliable. Regardless of how late the entry, the information documented must be accurate and complete. Late entries should be clearly marked as a late entry i.e. documenting the date and time of the entry, and the date and time that the care was given or when the event took place.

Corrections
Corrections are made in a timely, honest and forthright manner. Place brackets at the beginning and end of the error and then neatly drawing a single line through the error and document error and initial above the incorrect entry. The original information must remain visible or retrievable in the health record. Document the new entry including the date, time and your signature and status

Documentation Principles
Do not delete or alter an entry made by another Health Care Professional. Do not use whiteout, erasers, highlighter or entries between lines. Do not leave blank lines between entries. If a blank line is inadvertently left, draw a line through the space so that no further entry can be documented.

Documentation Principles
When documentation of an entry continues from one page to the next, the bottom of the first page is to be signed off. Enter the date and time in the appropriate column on the next page and document in the Clinical Notes contd.

Abbreviations
Use abbreviations according to policy ADM 1 30 Abbreviations / Signs / Symbols Accepted
Note: We do not have any approved symbols.

Documenting for Others

The person who saw the event, or performed the action, documents in the record, except in situations such as, a cardiac arrest, when one Health Care Professional will be designated as recorder and will document the care provided by another Health Care Professionals.

Documenting for Others

In the event another Health Care Professional assists you in the care of your patient, it is acceptable for you to document the action and patients responses, noting the name of the other care provider that assisted, for example, in a critical incident such as a fall, or a telemetry report you received from a Critical Care Unit staff member.

Documenting for Others

Interventions initiated by another Health Care Professional, on your assigned patient such as, initiation of an IV will be documented by the Health Care Professional performing the intervention

Narrative Notes

Clinical Record
NORTH BAY GENERAL HOSPITAL CLINICAL RECORD
DATE HOUR FOCUS D: DATA A: ACTION E: EVALUATION SIGNATURE/STATUS

NARRATIVE NOTE FORMAT

There are four elements in Focus Charting: 1.) The Focus Column 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.

Focus
Narrative documentation on the Clinical Record begins with Focus identification. The Focus is documented utilizing a key word or phrase that communicates to the Multidisciplinary Team what is happening with the patient, or to identify a significant event in the course of therapy.

FOCUS
Focus charting is patient-centered rather than problem oriented and addresses the patients strengths, concerns.

Documentation describes the patients perspective and focuses on documenting the patients current status, progress toward goals/outcomes, and responses to interventions.

FOCUS
Includes present positive occurrences not just negative problems or needs. Based on patient concerns, diagnosis, behaviors, treatment/therapy and or response.

FOCUS
A focus will identify a change in a patients condition or behavior, such as disorientation to time, place and person.

A significant event in the patients treatment/therapy, such as, safety concerns, or initiation of Blood Transfusion

FOCUS
An acute change in condition such as fluid overload, or seizure etc. Monitoring and assisting in problems related to physiologic functions of hydration, nutrition, respiration, elimination.

Focus
Patient teaching or counselling
Consulting with physicians or other disciplines in collaborative or multidisciplinary care.

Focus
Findings such as; safety concerns, physician visit, monitoring, ADLs, or functional health patterns, determined during the admission assessment and ongoing assessments. A current patient concern or behavior, such as pain, swallowing, feeding, dressing.

A sign or symptom, such as, an abnormal Vital Sign.

Foci using Flow Sheet NB 114

Activity Hygiene Nutrition Elimination Oxygenation Safety Concerns/Injury IV Therapy / Medication Cast CMS Dressing Drainage Systems

Focus
Abnormal Lab Results Admission Airway impairment Allergic Reaction Anxiety Aspiration Cardiovascular Central Line Therapy Chest Tubes Code (White, Blue, and Pink etc.) Cognitive Impairment Confusion Comfort Constipation Coping CNS Status Dehydration DNR/Therapeutic Choices Dialysis Discharge Edema Falls Fatigue Family Dynamics / Concerns Fluid Balance Fever GI Status GU Status Health Teaching Hemorrhage / Bleeding High Risk/ Suicidal Hypotension Hypertension Hypothermia Hyperthermia

Focus
Incontinence Infection Isolation Mental / Emotional Status Nausea / Vomiting Neurovascular Musculoskeletal Pain Control Physician/Visit/Assist/Notified Physical Status Respiratory Status Restraints Skin Integrity / Wound Care Spiritual Interventions Swallowing Substance Abuse Teaching Telemetry Transfer Vital Signs Wound Care

DAE
Documentation of DAE will follow the Focus entry. The notes will be structured using the following categories.

D Data A Action E Evaluation These categories are meant as a guide to assist the caregiver in documenting all relevant data in a structured format. All entries will begin with a Focus. Components of DAE can be charted alone or out of sequence.

#2

Data:

Document by writing a D: on the Clinical Record followed by your findings related to the stated focus.

Data is, but not limited to:

Subjective and /or objective information that supports the stated focus or describes the patient status at the time of a significant event or intervention.

Data:
Subjective Data is information a patient tells the caregiver. Record patient statements, documenting exact quotes or paraphrased conversation.
Information can come from patient, family, or from other Multidisciplinary Team Members.

Data:
Objective data includes all relevant information obtained from sources other than verbal expressions.
Objective data can be measured, seen, heard, touched, or smelled

#3

Action:
Document by writing an A: on the Clinical Record followed by completed or planned interventions based on the caregivers assessment of the patients status.

Actions are, but not limited to:

Actions taken in response to the stated focus. Concrete actions performed that assist the patient in reaching expected outcomes. Medical treatments as ordered by physicians.

Actions
Treatments or interventions such as, teaching protocols, initiated and provided by Health Care Professionals.
Future actions or plans that have been initiated

NOTE:

ACTIONS may be added to modify the intervention so progress is made toward the expected outcome

#4

Evaluation:
Document by inserting an E: on the Clinical Record followed by a description of the impact of the interventions and/or treatments on patients response.

Evaluation is, but not limited to:

Care provided and the response to actions, including monitoring data not captured on a flow sheet. The progress towards goals /outcomes or the lack of progress.

Focus Note
Date/Hour June 16/07 0730 Focus Nausea and Vomiting D:Data A:Action E:Evaluation Signature D: Complains of nausea A: Antiemetic and reassurance given Cool cloth applied to forehead. K basin at bedside-----------------------------E:States nausea has subsided.---

0800

Nausea and Vomiting

D. Smith R.N. D. Smith R.N.

Note:

Components of DAE can be charted alone or out of sequence.

Focus Note
Date/Hour August 16/06 0900 Focus Pain D:Data A:Action E:Evaluation Signature D: C/O pain in lower abdomen. States: feels like a stabbing knife like pain that comes and goes. Pain scale at 8. Diaphoretic . BP 150/100, pulse strong and bounding at 120bpm. Abdomen soft, bowel sounds heard, abdominal dressing dry and intact.----------------A: IM analgesic given and reassurance given . E: States pain is now 3 . BP 120/80, Pulse 82, diaphoresis has subsided. Analgesic effective ,settled in bed.------------------------------

I. Govis RN I. Govis RN

0910

Pain

Accountability
Sign name and status, after documentation entry in the designated column on the Clinical Record.

Student Documentation
All students documenting on the Clinical Record must document according to the charting methodology practiced at the North Bay General Hospital. Charting must be reviewed by the Instructor or Preceptor prior to the end of shift.

Flow sheets and Checklists

Flow sheets and checklists may be used as an adjunct to document routine and ongoing assessments and observations such as personal care, vital signs, intake and output, etc. Information recorded on flow sheets or checklists does not need to be repeated on the Clinical Record.

Flow sheets and checklists

When an activity or treatment was not carried out, or was different from the standard of care, it is necessary to document in the Clinical Record using a focus note.

NOTE: An asterisk * documented on the flow

sheet or checklist indicates that further documentation is required in the Clinical Record

Note:
In the event standard documentation is not possible i.e. written or computer based entry, dictation may be used. e.g. visually impaired.

Electronic Version

REFERENCES
Charting made Incredibly Easy, Lippincott Williams & Wilkins,2006 College of Nurses of Ontario, Practice Standard Documentation, Toronto Ontario. 2005
E-Learning Centre, College of Nurses of Ontario

2006. www.cno.org

Lampe, S., Focus Charting Documentation for Patient-Centered Care, Minneapolis, Minnesota, 1997 Laura Burke and Judy Murphy, Charting By Exception Applications, Milwaukee, Wisconsin. 1995 .

 Registered Nurses Association of British Columbia, Nursing Documentation, British Columbia, 2003 A Legal Perspective on Documentation and Charting, by Kristin Taylor and Michele M. Warner, in / Risk Management in Canadian Health Care/ Volume 8, Number 5, October 2006. ISBN 433-41589-4 Nursing Documentation Charting Recording and Reporting Eggland & Heinemann, 1994

College of Registered Nurses of Nova Scotia, Documentation Guidelines for Registered Nurses, Halifax Nova Scotia,2005 Reviewed by : Andrea McLellan Risk Management