Thursday, December 16, 2010

Focus charting

Focus charting is a type of nursing documentation which includes four categories, the focus, data, action and response. In the focus category, the nurse writes about his/her focus problem on a specific client. This includes the nursing diagnosis such as Ineffective Airway Clearance related to retained secretions. Then, the data will support the one that you have written in the focus. For example, that you have written Ineffective Airway Clearance, the data that you can write is the respiratory rate, (which happens to be abnormal), (+) productive cough (write the consistency, color,), presence of pallor and cyanosis, and also the Oxygen Saturation. Take note that in focus charting we avoid data's that are not related to the focus. That's why it was called FOCUS charting because you need to FOCUS on the problem itself.

 In the action category, you need to write what are the actions you have done to the client. It is also important that you need to align your action to your data. For example, I wrote Respiratory Rate of 37 breaths per minute, beside it, you can write "Monitored vital signs especially Respiratory Rate." Then, I also wrote (+) productive cough with color of whitish and thick consistency. You can write "Assessed client's cough and sputum; Noted for the color and consistency of the sputum." 

In the response corner, you will write what was the client’s response to your intervention. For example, the client stated. "My cough was decreased and I can breath as clear as now." After that, your signature must be displayed “Juan Dela Cruz, R.N.”.

The advantage of focus charting is it’s in the holistic emphasis on the client and priorities were ease in charting. It easily identifies critical client issues; facilitates communication among all disciplines; improves time efficiency in documentation; improves concise entries that would not duplicate client’s information that was already in the information/flow sheet/checklist.

The guidelines in FDAR includes: Focus charting must be evident every shift; it must be patient-oriented not nursing task-oriented; you must indicate date and time on the first column; separate the topic words from the body notes, Focus in the second column, data, action and response on the third column.

Some of the hospital provides five columns to be more specified. “Date/time” first column, “Focus” second column, “Data” third column, “Action” fourth column, Response at last column.

I hope I helped my colleagues out there. Be the best nurse by being competent together with the character. Godbless!

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