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.
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To provide the multidisciplinary team with a structured note format for documenting
Will reflect :
Documentation must be able to determine:
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.
Document by writing a “D:” on the Clinical Record followed by your findings related to the stated focus.
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” may be added to modify the intervention so progress is made toward the expected outcome
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.
Components of DAE can be charted alone or out of sequence.
Sign name and status, after documentation entry in the designated column on the Clinical Record.
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