Nurses' Charting: Focused Documentation

TheCommuter, BSN, RN

First and foremost, the medical record is a permanent aggregation of various documents that should furnish a comprehensively accurate picture of a patient's health status while he/she stayed at the hospital or other type of inpatient facility. After all, the medical record is a legal collection of documents and should be treated as such. Physicians, nurses, dietitians, mid-level providers such as nurse practitioners, social workers, case managers, other types of non-MD doctors such as podiatrists and other members of the multidisciplinary team contribute to every patient's medical record to formulate an all-encompassing picture of the patient's status along with the care that has been delivered.

The overwhelming majority of nurses have likely heard the commonplace saying that "If it was not charted, it was not done!" Thus, the patient's medical record must contain enough pertinent data to enable each member of the healthcare team to make clinical decisions and provide the patient's care in a smoothly integrated manner. The medical record is also interchangeably known as the patient's chart. In addition, there are multiple different ways for nurses to accurately document the nursing care they have provided in the medical record. In fact, no one way is correct or incorrect. However, some types of charting are more conducive to certain nursing specialties and settings than others.

The spotlight shall now be pointed toward the focused documentation style, which is a very underrated type of charting for nurses. The focused documentation method is highly advantageous because it is versatile and adaptable enough to be integrated into virtually all clinical settings that require accurate charting. Focused charting is also quick, short and concise, and these happen to be immensely helpful attributes in today's fast-paced healthcare environment that can leave harried nurses feeling as if time is always ticking away. Moreover, focused charting nicely organizes subjective and objective patient data followed by a clear-cut nursing action and one or more outcomes of the action. Additionally, focused charting swiftly intermingles several facets of the nursing process such as assessment, outcomes identification, planning, implementation and evaluation into one smallish paragraph.

Finally, the focused documentation style's main advantage is the reality that it focuses on the client's needs from a holistic point of view (Hope, 2012). In essence, focused documentation has a purposive focus that is set squarely onto the patient. Focused charting entails use of the data, action and outcome (DAO) format, more commonly known as the data, action and response (DAR) format. It is now time to read the following passages, which are examples of nurses' charting that employ the focused style of documenting.

D - Incision to left knee s/p total knee arthroplasty performed 24 hours ago is 14.5 centimeters long, approximated with staples, warm and dry to touch, with trace edema and a small amount of sanguinous, nonodorous drainage noted.
A - Left knee surgical incision was cleansed with dermal wound cleanser, patted dry with one 4x4 gauze and covered with a dry bordered non-adhesive dressing per physician's order.
O - Dressing remains clean, dry and intact at this time. Patient rates current pain level as a '1' using the numeric pain scale and is able to use the continuous positive motion (CPM) machine without any issues noted at this time.
D - Patient complains of headache lasting for 20 minutes duration; he describes the pain as dull and constant, and rates pain level as a '4' on a scale of 0 to 10 using the numeric pain scale.
A - Administered acetaminophen (Tylenol) 325mg, 2 tablets orally per PRN physician's order for mild pain rating.
O - Patient rated pain level as a 0 on a scale of 0 to 10 using the numeric pain scale upon reassessment. He is observed ambulating to the bathroom in his room using a rolling walker.

The focused method of documentation is versatile enough to be utilized in a wide assortment of clinical areas and specialties such as medical-surgical nursing, orthopedic nursing, long-term care, physical rehabilitation, addictions, psychiatric nursing, step-down, progressive care, private duty, home health, hospice, adult day care, and many other spheres. This particular type of charting tends to save time since it rapidly gets to the point: it describes the problem followed by the nursing action(s), and captures the results or outcomes that arose as a result of the interventions that had been carried out. Since nursing documentation is one of the more important tasks that nurses accomplish on a day to day basis, perhaps this style of charting might be tremendously useful in the area of nursing where you practice. As always, "If it was not charted, it was not done."

References

Hope, I. (2012). Charting for nurses. RN Speak. Retrieved from Charting for Nurses

Nurses' Charting: Focused Documentation

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