FOCUS CHARTING

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FOCUS CHARTING
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PURPOSE

• To provide the multidisciplinary team with a
  structured note format for documenting
• The patients health and well being
• The care provided
• The effect of the care and the continuity of the
  care.

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• Focus charting brings the focus of care back to
  the patient and patient concerns.

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Documentation

• Will reflect
• Collection and analysis of Data
• Actions taken
• Evaluation of outcomes by supporting critical
  thinking by the Health Care Professional in the
  clinical decision making process.

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Documentation Forms
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Documentation Forms

• Chart Documentation Signature Sheet NB 192
• Clinical Record NB 162 300 McLaren
• Appropriate NBGH Flowsheets
• Dictaphone/Tape Record

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Procedure

• Ensure the imprint of the addressograph on the
  Clinical Record corresponds to the correct
  patient.
• Document on appropriate forms approved by the
  North Bay General Hospital.
• Document the date and time of the care, or the
  event, in the designated columns on the Clinical
  Record.

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Procedure

• Black permanent ink is to be used when charting
• Each Health Care Professional who documents in
  writing in the patients record must sign and
  initial on the Chart Documentation Signature
  Sheet
• All documentation will be accompanied by
  appropriate identification of the caregiver
  making the entry onto the patient chart.

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Documentation Principles

• Documentation must be able to determine
• When an event happened
• What happened
• To whom it happened
• By whom it happened
• Why it happened
• The result of what happened

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Documentation Principles

• Maintain confidentiality of all patient
  information.
• Documentation will be retrievable
• Documentation is to be neat, legible, and
  non-erasable.
• Records must be an accurate, true and honest
  account of what occurred and when it occurred.

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Documentation Principles

• Documentation contains meaningful information,
  and avoids meaningless phrases, such as, good
  night, up and about, or usual day.
  Information documented must be relevant .
• Provides current, clear, complete, concise,
  concrete, documentation of the patients status
  with the least possible duplication of
  information.

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Documentation Principles

• Documentation must be reflective of observations
  not unfounded conclusions.
• Avoid statements such as, appears to and
  seems to when describing observations.
• Documentation must reflect the assessment,
  planning, implementation and evaluation of
  patient care.

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Documentation Principles

• Documentation will contain all clinical
  observations, actions taken by the health care
  providers, all treatments, as well as, the
  patients response to the care provided.

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Documentation Principles

• Document in a timely manner, during or as soon as
  possible, after the delivery of care. Never
  chart before the delivery of care.
• Chart in chronological order, documenting entries
  in sequence of events. Do not document in blocks
  of time i.e. August 16, 2006 1200 1600 hours

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Forgotten or Late Entries

• Forgotten or late entries are to be documented
  on the next available space within the Clinical
  Record.

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Forgotten or Late Entries

• Documentation must clearly state when the care
  was provided or when an event occurred, and when
  the documentation of the care/event occurred to
  be reliable. Regardless of how late the entry,
  the information documented must be accurate and
  complete. Late entries should be clearly marked
  as a late entry i.e. documenting the date and
  time of the entry, and the date and time that the
  care was given or when the event took place.

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Corrections

• Corrections are made in a timely, honest and
  forthright manner.
• Place brackets at the beginning and end of the
  error and then neatly drawing a single line
  through the error and document error and
  initial above the incorrect entry.
• The original information must remain visible or
  retrievable in the health record.
• Document the new entry including the date, time
  and your signature and status

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Documentation Principles

• Do not delete or alter an entry made by another
  Health Care Professional.
• Do not use whiteout, erasers, highlighter or
  entries between lines.
• Do not leave blank lines between entries. If a
  blank line is inadvertently left, draw a line
  through the space so that no further entry can be
  documented.

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Documentation Principles

• When documentation of an entry continues from one
  page to the next, the bottom of the first page is
  to be signed off. Enter the date and time in the
  appropriate column on the next page and document
  in the Clinical Notes contd.

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Abbreviations

• Use abbreviations according to policy ADM 1 30
  Abbreviations / Signs / Symbols Accepted
• Note We do not have any approved symbols.

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Documenting for Others

• The person who saw the event, or performed the
  action, documents in the record, except in
  situations such as, a cardiac arrest, when one
  Health Care Professional will be designated as
  recorder and will document the care provided by
  another Health Care Professionals.

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Documenting for Others

• In the event another Health Care Professional
  assists you in the care of your patient, it is
  acceptable for you to document the action and
  patients responses, noting the name of the other
  care provider that assisted, for example, in a
  critical incident such as a fall, or a telemetry
  report you received from a Critical Care Unit
  staff member.

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Documenting for Others

• Interventions initiated by another Health Care
  Professional, on your assigned patient such as,
  initiation of an IV will be documented by the
  Health Care Professional performing the
  intervention

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Structured Narrative Note Format DAE
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Narrative Notes
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Clinical Record
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NARRATIVE NOTE FORMAT

• There are four elements in Focus Charting
• 1.) The Focus Column identifies the content or
  purpose of the narrative entry and is separated
  from the body of the notes in order to promote
  easy data retrieval and communication.

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Focus

• Narrative documentation on the Clinical Record
  begins with Focus identification.
• The Focus is documented utilizing a key word or
  phrase that communicates to the Multidisciplinary
  Team what is happening with the patient, or to
  identify a significant event in the course of
  therapy.

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FOCUS

• Focus charting is patient-centered rather than
  problem oriented and addresses the patients
  strengths, concerns.
• Documentation describes the patients
  perspective and focuses on documenting the
  patients current status, progress toward
  goals/outcomes, and responses to interventions.

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FOCUS

• Includes present positive occurrences not just
  negative problems or needs.
• Based on patient concerns, diagnosis, behaviors,
  treatment/therapy and or response.

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FOCUS

• A focus will identify a change in a patients
  condition or behavior, such as disorientation to
  time, place and person.
• A significant event in the patients
  treatment/therapy, such as, safety concerns, or
  initiation of Blood Transfusion

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FOCUS

• An acute change in condition such as fluid
  overload, or seizure etc.
• Monitoring and assisting in problems related to
  physiologic functions of hydration, nutrition,
  respiration, elimination.

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Focus

• Patient teaching or counselling
• Consulting with physicians or other disciplines
  in collaborative or multidisciplinary care.

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Focus

• Findings such as safety concerns, physician
  visit, monitoring, ADLs, or functional health
  patterns, determined during the admission
  assessment and ongoing assessments.
• A current patient concern or behavior, such as
  pain, swallowing, feeding, dressing.
• A sign or symptom, such as, an abnormal Vital
  Sign.

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Foci using Flow Sheet NB 114

• Activity
• Hygiene
• Nutrition
• Elimination
• Oxygenation
• Safety Concerns/Injury
• IV Therapy / Medication
• Cast
• CMS
• Dressing
• Drainage Systems

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Focus
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Focus

• Incontinence
• Infection
• Isolation
• Mental / Emotional Status
• Nausea / Vomiting
• Neurovascular
• Musculoskeletal
• Pain Control
• Physician/Visit/Assist/Notified
• Physical Status
• Respiratory Status
• Restraints
• Skin Integrity / Wound Care
• Spiritual Interventions
• Swallowing
• Substance Abuse
• Teaching
• Telemetry
• Transfer

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DAE

• Documentation of DAE will follow the Focus entry.
  The notes will be structured using the following
  categories.

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• D Data
• A Action
• E Evaluation
• These categories are meant as a guide to assist
  the caregiver in documenting all relevant data in
  a structured format. All entries will begin with
  a Focus. Components of DAE can be charted
  alone or out of sequence.

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DATA
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Data

• Document by writing a D on the Clinical
  Record followed by your findings related to the
  stated focus.

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Data is, but not limited to

• Subjective and /or objective information that
  supports the stated focus or describes the
  patient status at the time of a significant event
  or intervention.

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Data

• Subjective Data is information a patient tells
  the caregiver. Record patient statements,
  documenting exact quotes or paraphrased
  conversation.
• Information can come from patient, family, or
  from other Multidisciplinary Team Members.

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Data

• Objective data includes all relevant information
  obtained from sources other than verbal
  expressions.
• Objective data can be measured, seen, heard,
  touched, or smelled

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ACTION
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Action

• Document by writing an A on the Clinical
  Record followed by completed or planned
  interventions based on the caregivers assessment
  of the patients status.

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Actions are, but not limited to

• Actions taken in response to the stated focus.
• Concrete actions performed that assist the
  patient in reaching expected outcomes.
• Medical treatments as ordered by physicians.

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Actions

• Treatments or interventions such as, teaching
  protocols, initiated and provided by Health Care
  Professionals.
• Future actions or plans that have been initiated

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NOTE

• ACTIONS may be added to modify the intervention
  so progress is made toward the expected outcome

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EVALUATION
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Evaluation

• Document by inserting an E on the Clinical
  Record followed by a description of the impact
  of the interventions and/or treatments on
  patients response.

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Evaluation is, but not limited to

• Care provided and the response to actions,
  including monitoring data not captured on a flow
  sheet.
• The progress towards goals /outcomes or the lack
  of progress.

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Focus Note
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Note

• Components of DAE can be charted alone or out
  of sequence.

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Focus Note
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Accountability

• Sign name and status, after documentation
  entry in the designated column on the Clinical
  Record.

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Student Documentation

• All students documenting on the Clinical Record
  must document according to the charting
  methodology practiced at the North Bay General
  Hospital.
• Charting must be reviewed by the Instructor or
  Preceptor prior to the end of shift.

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Flow sheets and Checklists

• Flow sheets and checklists may be used as an
  adjunct to document routine and ongoing
  assessments and observations such as personal
  care, vital signs, intake and output, etc.
  Information recorded on flow sheets or checklists
  does not need to be repeated on the Clinical
  Record.

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Flow sheets and checklists

• When an activity or treatment was not carried
  out, or was different from the standard of care,
  it is necessary to document in the Clinical
  Record using a focus note.
• NOTE An asterisk documented on the flow
  sheet or checklist indicates that further
  documentation is required in the Clinical Record

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Note

• In the event standard documentation is not
  possible i.e. written or computer based entry,
  dictation may be used. e.g. visually impaired.

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Electronic Version
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REFERENCES

• Charting made Incredibly Easy, Lippincott
  Williams Wilkins,2006
• College of Nurses of Ontario, Practice Standard
  Documentation, Toronto Ontario. 2005
• E-Learning Centre, College of Nurses of Ontario
  2006. www.cno.org
• Lampe, S., Focus Charting Documentation for
  Patient-Centered Care, Minneapolis, Minnesota,
  1997
• Laura Burke and Judy Murphy, Charting By
  Exception Applications, Milwaukee, Wisconsin.
  1995 .

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• Registered Nurses Association of British
  Columbia, Nursing Documentation, British
  Columbia, 2003
• A Legal Perspective on Documentation and
  Charting, by Kristin Taylor and Michele M.
  Warner, in / Risk Management in Canadian Health
  Care/ Volume 8, Number 5, October 2006. ISBN
  433-41589-4
• Nursing Documentation Charting Recording and
  Reporting Eggland Heinemann, 1994
• College of Registered Nurses of Nova Scotia,
  Documentation Guidelines for Registered Nurses,
  Halifax Nova Scotia,2005
• Reviewed by Andrea McLellan Risk Management