focus charting l.
Download
Skip this Video
Loading SlideShow in 5 Seconds..
FOCUS CHARTING PowerPoint Presentation
Download Presentation
FOCUS CHARTING

Loading in 2 Seconds...

play fullscreen
1 / 67

FOCUS CHARTING - PowerPoint PPT Presentation


  • 752 Views
  • Uploaded on

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.

loader
I am the owner, or an agent authorized to act on behalf of the owner, of the copyrighted work described.
capcha
Download Presentation

PowerPoint Slideshow about 'FOCUS CHARTING' - Albert_Lan


An Image/Link below is provided (as is) to download presentation

Download Policy: Content on the Website is provided to you AS IS for your information and personal use and may not be sold / licensed / shared on other websites without getting consent from its author.While downloading, if for some reason you are not able to download a presentation, the publisher may have deleted the file from their server.


- - - - - - - - - - - - - - - - - - - - - - - - - - E N D - - - - - - - - - - - - - - - - - - - - - - - - - -
Presentation Transcript
purpose
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.
documentation
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 forms7
Documentation Forms
  • Chart Documentation Signature Sheet NB 192
  • Clinical Record NB 162 300 McLaren
  • Appropriate NBGH Flowsheets
  • Dictaphone/Tape Record
procedure
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.
procedure9
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 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 principles11
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 principles12
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 principles13
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 principles14
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 principles15
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
  • Forgotten or late entries are to be documented on the next available space within the Clinical Record.
forgotten or late entries17
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
  • 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 principles19
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 principles20
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
Abbreviations
  • Use abbreviations according to policy ADM 1 – 30 Abbreviations / Signs / Symbols – Accepted
  • Note: We do not have any approved symbols.
documenting for others
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 others23
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 others24
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
slide25

Structured

Narrative Note

Format

DAE

narrative note format
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
Focus
  • Narrative documentation on the Clinical Record begins with Focus identification.
  • The Focus is documented utilizing akey 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.
focus30
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.
focus31
FOCUS
  • Includes present positive occurrences not just negative problems or needs.
  • Based on patient concerns, diagnosis, behaviors, treatment/therapy and or response.
focus32
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
focus33
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.
focus34
Focus
  • Patient teaching or counselling
  • Consulting with physicians or other disciplines in collaborative or multidisciplinary care.
focus35
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
Foci using Flow Sheet NB 114
  • Activity
  • Hygiene
  • Nutrition
  • Elimination
  • Oxygenation
  • Safety Concerns/Injury
  • IV Therapy / Medication
  • Cast
  • CMS
  • Dressing
  • Drainage Systems
focus38
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
  • Vital Signs
  • Wound Care
slide39
DAE
  • Documentation of DAE will follow the Focus entry. The notes will be structured using the following categories.
slide40
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.
slide41
#2

DATA

slide42
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
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.
slide44
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.
slide45
Data:
  • Objective data includes all relevant information obtained from sources other than verbal expressions.
  • Objective data can be measured, seen, heard, touched, or smelled
slide46
#3

ACTION

action
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 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
Actions
  • Treatments or interventions such as, teaching protocols, initiated and provided by Health Care Professionals.
  • Future actions or plans that have been initiated
slide50
NOTE:

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

slide51
#4

EVALUATION

evaluation
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
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.
slide55
Note:

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

accountability
Accountability

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

student documentation
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
  • 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 checklists62
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
slide63
Note:
  • In the event standard documentation is not possible i.e. written or computer based entry, dictation may be used. e.g. visually impaired.
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 .

REFERENCES
slide67
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