FOCUS CHARTING

 A method of organizing health

information in the individual’s record

 A systematic approach to
documentation using terminology to
describe individual’s health status and
nursing action

 Should be written by a registered nurse

ELEMENTS OF FOCUS
CHARTING

F-ocus
D-ata
A-ction
R-esponse
ELEMENTS OF FOCUS CHARTING

FOCUS
 Identifies the content or purpose of the narrative entry
 separated from the body of the notes
 for easy data retrieval & communication

DATA
 Subjective and objective information
 supports the focus
 describes observation at the time of the significant
event
ACTION
 Nursing interventions performed & planned to be
performed
 protocols and procedures initiated

RESPONSE
 Describes the individual’s response to medical/nursing
care.
 Outcomes of the action/intervention taken
GENERAL Guidelines
 Indicateshift (7-3, 3-11,11-7) for every change of shift
before chart entry.
 Focus must be evident at least once every shift.
 Must be focus-oriented and not nursing task-
oriented.
 Start the entry by indicating the focus note on the
first column.
 Below the focus, indicate the date and time of
entry on the same column.
GENERAL GUIDELINES

 Separate the body of notes

(Data, Action, Response) on the next column.
 Sign out each DAR entry with full signature above
a printed full name (stamp pad).
 Document only patient’s concern and/or plan of
care (e.g health teaching) per shift.
 Hence, general notes are never allowed
SPECIFIC GUIDELINES

 Begin with a comprehensive assessment of the

patient using inspection, palpation, percussion
and auscultation (IPPA)
 Establish a focus of care to be addressed in the
progress notes.
 Document entry related to the focus in the DAR
section of the form. An entry maybe one or any
combination of data, action, response.
 Data, action, response only contain information
related to the focus.
SPECIFIC GUIDELINES

 Response statements are documented after

nursing/medical interventions are implemented.
 Information from all three categories (DAR) should
be used only as they are available or relevant.
Example:
 Data and Action are recorded
at one hour
 Response is not added until later
when the patient outcome is
evident.
SPECIFIC GUIDELINES
Action & Response are repeated w/o additional data

 to show the sequence of decision making

 based on evaluating patient response to the initial
intervention
SAMPLE FOCUS
 Admission
 Reassessment
 Discharge
 New laboratory order
 when lab work-up can be R/T a focus
 when lab work-up cannot be R/T a focus
 Notification of Physician
 Pre-operative Care
 Intrapartum/Postpartum Care
 Neonatal assessment
 Refusal of Treatment/Medicine
QUESTIONS??????
THANK YOU SO
MUCH!!!