Download Documentation Methodology

FOCUS CHARTING
PURPOSE
To provide the multidisciplinary team
with a structured note format for
documenting
 The patient’s health and well being
 The care provided
 The effect of the care and the
continuity of the care.
 Focus charting brings the focus of
care back to the patient and patient
concerns.
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.
Documentation Forms
Documentation Forms
Chart Documentation Signature
Sheet NB 192
Clinical Record NB 162 300 McLaren
Appropriate NBGH Flowsheets
Dictaphone/Tape Record
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.
Procedure
 Black permanent ink is to be used
when charting
 Each Health Care Professional who
documents in writing in the patient’s
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.
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
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.
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 patient’s
status with the least possible duplication of
information.
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.
Documentation Principles
 Documentation will contain all clinical
observations, actions taken by the
health care providers, all treatments,
as well as, the patient’s response to
the care provided.
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
Forgotten or Late Entries
 Forgotten or late entries are to be
documented on the next available
space within the Clinical Record.
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.
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
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.
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 “ cont’d.”
Abbreviations
 Use abbreviations according to policy
ADM 1 – 30 Abbreviations / Signs /
Symbols – Accepted
 Note: We do not have any approved
symbols.
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.
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.
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
Narrative Notes
Clinical Record
NORTH BAY GENERAL HOSPITAL
CLINICAL RECORD
DATE
HOUR
FOCUS
D: DATA
A: ACTION
E: EVALUATION
SIGNATURE/STATUS
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.
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.
FOCUS
 Focus charting is patient-centered rather
than problem oriented and addresses the
patient’s strengths, concerns.
 Documentation describes the patient’s
perspective and focuses on documenting
the patient’s current status, progress
toward goals/outcomes, and responses
to interventions.
FOCUS
 Includes present positive occurrences
not just negative problems or needs.
 Based on patient concerns, diagnosis,
behaviors, treatment/therapy and or
response.
FOCUS
 A focus will identify a change in a patient’s
condition or behavior, such as disorientation
to time, place and person.
 A significant event in the patient’s
treatment/therapy, such as, safety
concerns, or initiation of Blood Transfusion
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.
Focus
 Patient teaching or counselling
 Consulting with physicians or other
disciplines in collaborative or
multidisciplinary care.
Focus
 Findings such as; safety concerns,
physician visit, monitoring, ADL’s, 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.
Foci using Flow Sheet NB 114
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Activity
Hygiene
Nutrition
Elimination
Oxygenation
Safety Concerns/Injury
IV Therapy / Medication
Cast
CMS
Dressing
Drainage Systems
Focus
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Abnormal Lab Results
Admission
Airway impairment
Allergic Reaction
Anxiety
Aspiration
Cardiovascular
Central Line Therapy
Chest Tubes
Code (White, Blue, and Pink etc.)
Cognitive Impairment
Confusion
Comfort
Constipation
Coping
CNS Status
Dehydration
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DNR/Therapeutic Choices
Dialysis
Discharge
Edema
Falls
Fatigue
Family Dynamics / Concerns
Fluid Balance
Fever
GI Status GU Status
Health Teaching
Hemorrhage / Bleeding
High Risk/ Suicidal
Hypotension
Hypertension
Hypothermia
Hyperthermia
Focus
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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
Vital Signs
Wound Care
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.
#2
Data:
Document by writing a “D:” on the
Clinical Record followed by your
findings related to the stated focus.
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.
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.
Data:
 Objective data includes all relevant
information obtained from sources
other than verbal expressions.
 Objective data can be measured, seen,
heard, touched, or smelled
#3
Action:
Document by writing an “A:” on the
Clinical Record followed by completed
or planned interventions based on the
caregiver’s assessment of the patient’s
status.
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.
Actions
 Treatments or interventions such as,
teaching protocols, initiated and
provided by Health Care Professionals.
 Future actions or plans that have been
initiated
NOTE:
“ACTIONS” may be added to modify the
intervention so progress is made
toward the expected outcome
#4
Evaluation:
Document by inserting an ‘E:’ on the
Clinical Record followed by a
description of the impact of the
interventions and/or treatments on
patient’s response.
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.
Focus Note
Date/Hour
Focus
D:Data
June 16/07
0730
Nausea and
Vomiting
D: Complains of nausea
A: Antiemetic and reassurance given
Cool cloth applied to forehead. K basin
at bedside-----------------------------E:States nausea has subsided.---
0800
Nausea and
Vomiting
A:Action
E:Evaluation
Signature
D. Smith
R.N.
D. Smith
R.N.
Note:
Components of DAE can be charted
alone or out of sequence.
Focus Note
Date/Hour
Focus
D:Data
August 16/06
0900
Pain
D: C/O pain in lower abdomen. States: “feels
like a stabbing knife like pain that comes and
goes.” Pain scale at 8. Diaphoretic . BP
150/100, pulse strong and bounding at
120bpm. Abdomen soft, bowel sounds heard,
abdominal dressing dry and intact.----------------A: IM analgesic given and reassurance given .
0910
Pain
A:Action
E:Evaluation
E: States pain is now 3 . BP 120/80, Pulse
82, diaphoresis has subsided. Analgesic
effective ,settled in bed.------------------------------
Signature
I. Govis RN
I. Govis RN
Accountability
Sign name and status, after
documentation entry in the
designated column on the Clinical
Record.
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.
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.
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
Note:
 In the event standard documentation
is not possible i.e. written or
computer based entry, dictation may
be used. e.g. visually impaired.
Electronic Version
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 .
 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