FOCUS

CHARTING
 Focus Charting
a method for organizing health
information in the individual’s record
a systematic approach to
documentation using nursing
terminologies to describe individual’s
health status and nursing action
PARTS
• Date and Time
• Focus
• Progress Notes (DAR)
 PROGRESS
DATE/TIME FOCUS
NOTES
FOCUS
• identifies the content or purpose of
the narrative entry
FOCUS can be:
• a nursing diagnosis
Ex: Fluid Volume Deficit
Ineffective Thermoregulation
Self-Care Deficit
FOCUS can be:
• a client problem/concern
Ex: Nausea
Chest Pain
FOCUS can be:
• signs/symptoms of potential importance
Ex: Fever
Hypertension
Lethargy
FOCUS can be:
• a significant change in client’s status
Ex: Seizure
Respiratory Distress
FOCUS can be:
• a significant event in client’s care
Ex: Pre-operative Assessment
Discharge Planning
Catheterization
DATA
• subjective/objective information
describing and/or supporting the
Focus
ACTION
• nursing interventions performed
RESPONSE
• describes the effects of interventions
and whether the goal was met
DATE/ FOCUS PROGRESS NOTES
TIME
03/08/14 Chest Pain D > “Sumasakit ang dibdib ko”
10 am > midclavicular line
> 4/10 on pain scale
10:15 am A > medicated with Isordil 5 mg tab
SL as ordered
12 pm R > “Nabawasan na ang sakit ng
dibdib ko”
> pain score of 2/10
 DATE/ FOCUS PROGRESS NOTES
TIME
03/08/14 Health Teaching: R > able to change own
10 am Dressing Change abdominal dressing using
aseptic technique

Response is used alone to indicate if a

care of plan goal has been
accomplished
DATE/
FOCUS PROGRESS NOTES
TIME
03/08/14 Post-Transfer D > Received from RR via
10 am Assessment stretcher
> awake and alert
> with ongoing IVF of # 1
PNSS i L at 700 cc level;
infusing well at 30 gtts/min
at right metacarpal vein
via IV catheter G# 18
> foley catheter (Fr 16) in
place draining yellow
urine
 Data is used alone when the purpose
of the note is to document assessment
Mr. Dalisay, 56 years old, male, arrived at the ER
with a chief complaint of chest pain radiating to the
left upper extremity. He rates the pain as 8/10
especially upon exertion. The patient is diaphoretic,
with facial grimace, cold clammy skin, and sense of
impending doom. Bipedal pitting edema (+3) is
evident and crackles are heard upon auscultation.
The patient appears apprehensive and states, “I
don’t have enough energy to perform self-care.”
Vital signs were taken as follows: T = 35.6 C,
PR = 118 bpm, RR = 25 cpm, BP = 80/50 mmHg,
O2 Sat = 94-95%
At the ER, the NOD transcribed the following
doctor’s order:
• Please admit patient to ICU
• Secure consent for admission
• NPO temporarily then may have low salt,
low fat with SAP if tolerated
• Limit oral fluid intake to 1 L/day
• Request for: CBC, Trop I, Na, K, crea, FBS, LP,
ECG and CXR-PA view
• Start initial venoclysis of PNSS iL x KVO rate
(microset)
• Vital signs qh
• CBR s toilet privileges
• Hook to O2 at 1-2 LPM via nasal
cannula
• Attach to cardiac monitor
• Insert FBC (Fr 16) and attach to
urobag
• I and O q 2h
Meds:
• Aspirin ii tabs STAT then i tab OD
• Ketorolac 30 mg IVTT now then q6h for pain
• Cefuroxime 1.5 g IVTT as loading dose then
750 mg IVTT q8h ANST ( )
• Ranitidine 50 mg IVTT q6h
• Digoxin 0.25 mcg, i tab OD
• Isordil i tab SL now

Please refer to AP for any untoward

manifestation