focus charting

Is "focus charting" when you only comment on the abnormals? If so, then I usually include mental status & pain in my comments. I'll write something like: "Alert, oriented, resting in bed. Reports no pain." Plus, I throw in a line that relates to the diagnosis -- if pneumonia: "Lung sounds clear; intermittent, productive cough."

focus charting is data, action response. For example:

Focus- Pt. c/o SOB

Data- saO2 90%, RR 28, BP 100/60

Action- Elevated HOB to high fowlers, applied 2L o2 nasal cannula

Response- SaO2 95%, RR20, pt. denies SOB, resting comfortably.

I was just wondering what kind of note I would write in that format if there were no significant events during the shift.

I would think you could put something like this:

Focus- Pt's condition unchanged, no improvement, no declination

Data- saO2 90%, RR 28, BP 100/60, T 98.6, HR 98

Action- no changes, continue to follow care plan

Response- patient condition stable, resting comfortably.

I would think you could put something like this:

Focus- Pt's condition unchanged, no improvement, no declination

Data- saO2 90%, RR 28, BP 100/60, T 98.6, HR 98

Action- no changes, continue to follow care plan

Response- patient condition stable, resting comfortably.

I came on AllNurses this evening looking for an example of a focus note and found yours to be very helpful. It was one of those light bulb moments for me. So thank you for the example! :)

Our hospital does focus/problem charting as well in the DARE format and our charting comes with a flowsheet of your initial assessment as well as any following assessments. If the shift is "uneventful" meaning, no significant change in VS or condition. I like to put in procedures pt. left the unit for and who was visited by the pt.

ex. 1330 - A - pt transported via gourney to CT scan on 1L N/C. Pt. handoff communication form completed, no RN supervision necessary

1500 A- visited by Dr. Smith, aware of CT Chest and ABG results

then toward the end of your shift I would jot down something related to the reason why

the patient is in the hospital in the first place

D- Dx of pneumonia, Hx COPD on 1L O2 via NC with sats between 92-94% throughout shift. BP 134/85 RR 19 Oral temp 97.6 , sinus rhythm on monitor

R - denies pain, unchange in baseline status, appears in no distress, agrees with POC

E - continue with POC

Just know something ALWAYS happens, whether he is seen by Dr. so and so or the physical therapist, etc. I try not to double chart, however. Say the patient's got a Foley cath. I just check off the "FC" in our flowsheet along with the color and clarity. I do not have to go to the written part of our flowsheet and write pt with 16F F/C draining 950 cc since 0830 clear, yellow urine...unless there was a "problem" like he had clots which required irrigation, or the FC came out and a new one had to be re-inserted...

my day is super busy. Charting a novel doesn't always guarantee clear, concise documentation as well as I have no time for it. Straightforward and to the point is the best way to go in a hospital who does problem of focus charting.

Good luck, practice makes perfect

NYBaby, thanks for your response to this thread. I've been nursing for a year now and lately, I'm on the path to burnout. I'm on "holidays" at the moment getting refreshed before I go back to work and I really want to try and cut down on all the "extra" charting I do. In nursing school I was taught narrative but its hard to change. The fact of the matter is I have to. Flowsheets, focus charting (which my hospital does promote) and no-nonsense documentation is an way for me to become more efficient with my time. You're response was just the wake up call I needed. Thanks.

can i also ask help here?i have here a very long situation. and i'm new to using fdar. i need help pretty please. I have no idea how to make an fdar note on this situation.

Mrs. Ivory White, 67 was admitted to the medical-surgical unit with a diagnosis of deep vein thrombosis. Nurse A is also caring for several other patients, including two who are now in surgery, a newly admitted patient, and two who maybe discharged that morning. She begin her shift with the head-to-toe assessment of each patient.

Mrs. White is resting comfortably with an IV line infusing heparin. The Iv site, in her upper left arm, seems damp, so Nurse A decided to change the dressing. She assembled the necessary items, and as she reentered the room one of her other patient returns from surgery. To receive the post-op patient, she ask Grey, an unlicensed assistant, to reinforce Mrs. White's IV site.

The morning gets busier as Nurse A's assigned a new admission when she passed Grey in the hall and asked about her other patient's, who says they're doing "fine".

Several hours later, sh finally have time to check on Mrs. White, who complains that her back is cold. When she mentioned this to Grey earlier, she says, he suggested the air conditioning vent might be blowing on her back and offered to adjust it. As Mrs. White explains that she is still cold, nurse A assessed her starting with her IV, and determined that the pump is running at the proper rate. She followed the line to Mrs. White's IV and noticed that the tubing is caught under her back. When Mrs. White turned to her side she discovered that the IV cannula is lying on the bed, which is very wet with IV fluid and some blood. Mrs. White probably pulled out the IV inadvertently earlier that morning. Nurse A recall the damp IV site and the need for a new dressing. Mrs. White may not have received heparin for several hours, placing her at risk for serious complications, such as pulmonary embolism.

Upon completion of the assessment, nurse A ask Grey if he reinforced the IV site,as earlier directed.He apoloized and told her he forgot after being asked to help another nurse withan urgent task. She asked him why he didn't return to check on Mrs. White IV site at some point during the morning. "I'm sorry" he says, "but that isn't in my job description. I asked the patients how they're doing, but I don't assess them the way you do."

Sorry to bother, but any response will be of great help.