FOCUS CHARTING

PURPOSE

To provide the multidisciplinary team with a structured note format for documenting

The patient’s 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 patient’s 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 patient’s 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 patient’s 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 “ cont’d.”

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

NORTH BAY GENERAL HOSPITALCLINICAL RECORD

DATE HOUR FOCUS D: DATA A: ACTION E: EVALUATION SIGNATURE/STATUS  

 

 

 

 

 

 

 

Clinical Record

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 patient’s strengths, concerns.

Documentation describes the patient’s perspective and focuses on documenting the patient’s 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 patient’s

condition or behavior, such as disorientation to time, place and person.

A significant event in the patient’s 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, ADL’s, 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

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

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 caregiver’s assessment of the patient’s 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 patient’s 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 Focus D:Data A:Action E:Evaluation Signature

June 16/07 0730

0800

Nausea and Vomiting

Nausea and Vomiting

D: Complains of nauseaA: Antiemetic and reassurance givenCool cloth applied to forehead. K basin

at bedside------------------------------E:States nausea has subsided.---

D. Smith R.N.

D. Smith R.N.

Note:

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

Focus NoteDate/Hour Focus D:Data A:Action E:Evaluation Signature

August 16/06 0900

Pain 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 .

I. Govis RN

0910 Pain E: States pain is now 3 . BP 120/80, Pulse 82, diaphoresis has subsided. Analgesic effective ,settled in bed.------------------------------

I. Govis RN

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