Scribd Logo
Upload

Welcome to Scribd!

  • 3K views

    Charting (Sample)

    Uploaded by

    Zarah Joy Tabuyan
    The document describes the Focus Charting system used at Windsor Regional Hospital for documenting patient care. It has several advantages including being flexible, promoting interdisciplinary documentation organized by the patient's focus or priority issue, and facilitating communication between care team members. The Focus Charting system uses various components including Focus Lists to track patient issues, Flow Sheets for routine data, Care Plans to document care for each focus, and Progress Notes using a DAR (Data, Action, Response) structure to record assessments, interventions, and patient responses over time.

    Copyright:

    Attribution Non-Commercial (BY-NC)
    Download as PDF, TXT or read online from Scribd

    Charting (Sample)

    Uploaded by

    Zarah Joy Tabuyan
    3K views9 pages
    The document describes the Focus Charting system used at Windsor Regional Hospital for documenting patient care. It has several advantages including being flexible, promoting interdisciplinary documentation organized by the patient's focus or priority issue, and facilitating communication between care team members. The Focus Charting system uses various components including Focus Lists to track patient issues, Flow Sheets for routine data, Care Plans to document care for each focus, and Progress Notes using a DAR (Data, Action, Response) structure to record assessments, interventions, and patient responses over time.

    Copyright

    © Attribution Non-Commercial (BY-NC)

    Available Formats

    PDF, TXT or read online from Scribd

    Did you find this document useful?

    Is this content inappropriate?

    The document describes the Focus Charting system used at Windsor Regional Hospital for documenting patient care. It has several advantages including being flexible, promoting interdisciplinary documentation organized by the patient's focus or priority issue, and facilitating communication between care team members. The Focus Charting system uses various components including Focus Lists to track patient issues, Flow Sheets for routine data, Care Plans to document care for each focus, and Progress Notes using a DAR (Data, Action, Response) structure to record assessments, interventions, and patient responses over time.

    Copyright:

    Attribution Non-Commercial (BY-NC)
    Download as PDF, TXT or read online from Scribd
    Download as pdf or txt
    3K views9 pages

    Charting (Sample)

    Uploaded by

    Zarah Joy Tabuyan
    The document describes the Focus Charting system used at Windsor Regional Hospital for documenting patient care. It has several advantages including being flexible, promoting interdisciplinary documentation organized by the patient's focus or priority issue, and facilitating communication between care team members. The Focus Charting system uses various components including Focus Lists to track patient issues, Flow Sheets for routine data, Care Plans to document care for each focus, and Progress Notes using a DAR (Data, Action, Response) structure to record assessments, interventions, and patient responses over time.

    Copyright:

    Attribution Non-Commercial (BY-NC)
    Download as PDF, TXT or read online from Scribd
    Download as pdf or txt
    You are on page 1of 9
    At a glance
    Powered by AI
    The key takeaways are that Focus Charting is the accepted documentation system at Windsor Regional Hospital. It centers on the nursing process and promotes communication between care team members.

    The Focus Charting System is the accepted documentation system at Windsor Regional Hospital. It is flexible, centers on the nursing process, promotes communication, and encourages regular documentation.

    The components of the Focus Charting system include focus lists, care plans, progress notes, and flow sheets. A focus describes the focus of actions and the DAR format is used to document assessments, interventions, and responses.

    FOCUS CHARTING

    The Focus Charting System is the accepted documentation system at Windsor Regional Hospital.

    Advantages of Focus Charting


    Flexible enough to adapt to any clinical practice setting and promotes interdisciplinary documentation Centers on the nursing process, including assessment, planning, implementation and evaluation Information is easy to find because data is organized by the focus It promotes communication between all care team members Encourages regular documentation of patient responses to care Helps organize documentation so that it is concise and precise Can be easily adapted to computer based documentation systems

    Focus Charting Combines:


    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

    The Focus System Uses:

    Focus Lists

    Flow Sheets

    Care Plans

    Progress Notes

    Developing the Focus


    Refers To
    A sign or symptom A patient behaviour An acute change in the patients condition A significant event in the patients therapy A special patient need

    Example
    Hypotension, or chest pain Inability to ambulate Loss of consciousness or increase in blood pressure Surgery Discharge planning need

    A focus may also be written in the format of a nursing diagnosis.

    The Focus List


    A FOCUS LIST sheet is used as an index or quick reference for what you will find in the progress notes. All disciplines should record on the focus list.

    1 2

    Inability to ambulate Chest pain

    11/12/01 11/12/01

    Nursing, PT Nursing

    Enter the Focus 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 reinstated The discipline entering the focus should identify themselves.

    Additional Information
    Focus Lists must be regularly updated and expanded as the patients condition changes. Note: At discharge, focus list needs to be checked to ensure that all the foci have been addressed and / or resolved.

    The Use of Care Plans


    Once a focus has been identified, a plan of care needs to be documented. 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 others input in order to make it individualized. Care plans should be regularly updated as required. A Clinical Pathway is another example of a care plan available at WRH.

    Flow Sheets
    There are numerous pre-printed flow 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).

    Examples of Flow Sheets


    vital signs record medication record intake and output post op flow sheet wound assessment record

    Things to Remember
    All flow sheets must be correctly dated and must contain the patients name on both sides. All entries on the flow sheets 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.

    Progress Notes
    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 to another, or at the time of discharge

    When writing progress notes you should include information about: The details about the patients condition (assessment data) The interventions or nursing actions implemented and their effectiveness The patients response to care

    How to Complete a Progress Note


    When starting a note the focus is documented first. Notes are chronologically entered. 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 In focus charting the structure of the progress note that follows the focus uses a DAR outline: Data, Action Response

    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.

    is an acronym

    Data - subjective & objective patient assessment data that supports 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.

    Things to Remember About Progress Notes


    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.
    Date 20 June 98 Time 1000 Nrsg. Wound Dressing D - Moderate amount of purulent, foul smelling drainage from abdominal incision noted. Suture line red and swollen and warm to touch, T-39.5 Joan Smith R.N. 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 and dry drsg. Applied.------------------------------------------------------------------------Joan Smith R.N. R - T38. Patient states incisional pain improving. Dressing remains dry and intact, no discharge noted. Antibiotic initiated as ordered. ----------------------------------------------------------------------------Joan Smith R.N. Joan Smith R.N.

    1230

    There may be more than one focus that requires charting at one time Progress notes must have a signature after each entry

    Write patient progress notes only when necessary. The goal is to minimize duplication of information and to save time.
    Date 22 June 98 Time 1500

    Nrsg. #1 D - pt. c/o of chest pain on inspiration, fatigue. T-39.5 at 1515, wheezy breath sounds, productive cough for purulent tenacious sputum. IV infusing. A - 02 at 3 litres, chest x-ray this am sputum

    Focus Charting Dos and Donts


    Progress notes can be improved by choosing language which is: Objective Precise Specific Thorough

    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. Poor Wording
    Eats poorly Patient confused Uncooperative Patient complaining of pain Good day Diuresing well Walking ad lib

    Good Wording
    Ate the meal and drank 80 ml fluid Patient unable to recognize family Refuses to assist with am care Complaining of constant, sharp RUQ abd. 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

    Remember to be factual, specific, precise, and thorough. Avoid summarizing or using value judgments.

    You might also like