Focus Data Action Responses

FDAR

Why Document?

1. Professional responsibility

2. Legal protection 3. Regulatory standards 4. Reimbursement

80% of Tertiary Private Hospitals in Metro Manila

Recommended Nurse Patient Ratio 1: 10 Functional

Total Patient Care

1:4 Minimum

1:6 Average
1:7 Maximum

FOCUS CHARTING

The content of the charting

juicy content of charting Delivery of care continuity of care is well established Legal aspect freedom from legal conflict

Dos 1.Do read what other providers have written before providing care and charting your care. 2.Do time and date all entries 3.Do use flow sheet keep information on flow sheets current. 4.Do write your own observation, sign and initial your own name.

5.Do describe patients behaviour. Use direct patient quotes. 6.Do the factual and complete. Do record exactly what happens to patient and cares given. 7.Do draw a single line thru an error. Mark this entry as error and sign your name 8.Do use next available chart forms. 9.Do write legibly .Do use ink. Do use acceptable chart forms. 10.Do use only approved abbreviations.

Not standardized abbreviations can only be used on the KARDEX not on the patients charts.

TSOC- To secure old chart OCAS- Old chart at station IOC - IM on call NICPD- Not in cardio pulmonary distress SF - Still for FU - Follow up RTF - Request to forward

Don'ts 1.Dont begin charting until you check the name and identifying no. on the patients charts and each page. 2.Dont chart procedures on care a in advance. 3.Dont clutter notes with repetitive on frequently charging data. 4.Dont make or sign on entry for someone else . Don't change an entry because someone else tells you to do.

 * Do not leave space ( if no charting )

Call Nurse and come to report then chart Enter chart and label as late entry

5.Dont label a patient or show bins 6.Dont try to cover up a mistake or incident by inaccuracy or omission. 7.Dont use wipe out or erase an error. Don't throw away error notes. 8.Dont squeeze in a missed entry or leave space for someone else who forgot to chart. 9.Dont use meaningless words and phrases such as good day or no complaints. 10.Dont use pencil or notebook .

Elements of FOCUS CHARTING

FOCUS - PROBLEM DATA - Assessment Subjective And Objective Data ACTION - Intervention/ CARE Rendered RESPONSE- Evaluation -What happened to the pt. As a result the action

Some of the FOCUS ideas are: MOBILITY/ACTIVITY ELIMINATION PAIN TRANSFER PROCEDURE NUTRITION SAFETY

WHAT BENIFIT US FROM FOCUS CHARTING

More time to patients and less time in charting
Head Clinical Area