Focus Charting - is a method for organizing health information in the individual's record. It is a systematic approach to documentation, using nursing terminology to describe individual's health status and nursing action. Focus
• a key word or diagnostic category from a nursing diagnosis or collaborative problem on the plan of care (action plan), i.e. skin integrity, coping, activity tolerance, self care deficit • a current individual concern or behavior,
i.e. nausea, chest pain, pre-op teaching, hospital admission • a sign or symptom of (possible) importance to the nursing and/or medical diagnosis or treatment plan, i.e. fever, constipation, hypertension, incontinence, lethargy • an acute change in an individual's condition,
i.e. respiratory distress, seizure, fever, discomfort
• a significant event in an individual's care,
i.e. begin treatment regimen (oxygen), change in diet, catheterization • a key word or phrase indicating compliance with a standard of care or agency policy, i.e. self medication teaching plan, transition
COMPONENTS OF A FOCUS NOTE:
Data: Subjective and/or objective information supporting the stated focus or describing observations at the time of significant events. Action: Nursing interventions performed, planned to be performed, and/or protocols and procedures initiated. Response: Description of individual's response to medical and/or nursing care. Statement that the Action Plan of Care outcomes have been attained or are progressing toward attainment.
Need: Comfort (or, Relief of pain)
D - Complaining of continuous, sharp pain in mid-abdominal incisional area. Crying. "I need something for pain now!" States pain is 9 on a scale of 10. A - Medicated with Demerol 75mg IM in LUOQ of left buttock. Repositioned on right side with pillow to abdomen to help splint wound. R - Patient stated pain was "much better" 30 minutes later and rated it 3 on a...