Focus Charting

PRIMARY PURPOSE OF CHARTING

1. Charting provides a way for health team

professionals to communicate with each other.

2. Charting provides a legal record that can be used

to protect the patient, the health professional and
health facility who provide care.

3. Charting provides the data needed for effective

interdisciplinary care and to ensure continuity
of care
Charting Tips
Avoid labeling
◦ Eliminate bias ( charting patient as rude might open door to questions about
your care)

Be specific (output 1500 cc’s instead of adequate

output)
Do not use redundant/vague/unnecessary words
◦ v/s taken and recorded - endorsed
◦ needs attended - kept rested
◦ fair - up and about
Charting Tips
Use appropriate abbreviations
Do not use short hand
Never ask someone to chart for you
Charting Tips
What to chart
◦ Establish baseline by charting complete assessment of patient.
◦ Chart significant changes
◦ Document teaching and discharge
◦ Document actions at patient behalf
◦ Communication of lab results
◦ Assessment findings/changes
Focus Charting
DESCRIBES THE PATIENT’S PERSPECTIVE AND FOCUSES
ON DOCUMENTING THE PATIENT’S CURRENT STATUS,
PROGRESS TOWARDS GOALS, AND RESPONSE TO INTERVENTIONS.
GENERAL GUIDELINES
1. FOCUS CHARTing must be evident once every shift.

2. Focus charting must be patient-oriented not task-oriented

3. Indicate the date and time of entry on the first column.

4. Separate the topic words for the body of notes

4.1 Focus note written on the first column above the time.
4.2 Data, action and response on the next column
5. Sign name for every time entry.

6.Document only patient’s concern and/or plan of care

per shift. General notes are not allowed.

7. Document patient’s status on admission, for every

transfer to/from another unit or discharge.

8. Follow the do’s and don’ts of focus charting.

 Specific Guidelines
1. Begin with a comprehensive assessment of the patient
using IPPA

2. Include in the assessment, collection of information

from the patient,family, existing health records and
other health care providers.

3.Document the four elements of focus charting as necessary

DATA
- the subjective and/or objective information supporting
the stated focus or describing the observations at the
time of a significant event
ACTION
- Describes the nursing interventions ( independent,
basic and perspective) past, present, future
RESPONSE
- Describes the patient outcome/response to
interventions or describes how the care plan
goals have been attained
 END
of
Presentation