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Focus charting is a type of documentation that is

based on the nursing process of assessment, planning,


implementation and evaluation to concentrate on a
particular issue and address it. The Data, Action and
Response approach (DAR) is used in this method of
charting and is meant to keep the information concise.
Charting is an integral part of nursing. Nurses are
responsible for documenting all care and changes in
the patient's condition.



Quality Nursing care

Vision
of FDAR

Quality of Records







DOCUMENTATION

Is the process of recording information in the medical
chart to support the original written work.
Documentation begins when the patient enters the
health care system ( Hospital)


ER
Medical Chart
it is the confidential document that contains detailed and
comprehensive information on the individual patient and
their care experience.
Purpose:
to serve as both medical and legal record of patient clinical
status, care, history, and care giver involvement.
Generally, physicians and nurses write most in the patients
chart. The documentation by the clinician (physician)
often focuses on diagnosis and prognosis based on their
physical assessment and history taking, while
documentation by the nursing team generally, focuses on
patient responses to treatment and details of day to day
progress.


In many institutions, the medical and nursing staff
may complete separate forms or areas of the chart
specific to their disciplines.


the training of our minds obedience to the rules
and character


Another reason for the standard of clear
documentation is the possibility of the legal use of the
record. When medical care is being referred to or
questioned by the legal system, the chart contents are
frequently cited in court. For all of these purposes,
certain practices that protect the integrity of the chart
and provide essential information are recommended
for adding information and maintaining the chart.


These practices include:
Date and time on all records.
Full patient name and other identifiers (i.e., medical
record number, date of birth) on all records.
Mark continued records clearly (i.e., if note continued on
reverse of page).
Sign each page of documentation
Use black, blue, and red non-erasable ink on hand written
records
Keep records in chronological order.
Prevent disposal or obliteration of any records.
Note documentation errors and correct clearly, i.e., by
drawing one line through the error and noting presence of
error or mistaken entry, initialling the area.
Do not alter a patients record.
Do not chart ahead of time.
Do not chart a symptom such as without pain.





Avoid excess empty space on the page.
Avoid abbreviations, use only universally accepted
abbreviations. And avoid the use of arrows / signs
or ( - ) ( + )
Avoid other unclear documentation, such as illegible
penmanship.
Avoid including contradictory information. For example,
if a nurse documents that a patient has complained of
abdominal pain throughout the shift, while the physician
documents that the patient is free of pain, these
discrepancies should be discussed and clarified.
Provide objective rather than subjective information. Do
not chart what someone else said, heard, felt, or smelled
unless information is critical. For example, do not allow
personality conflicts between staff to enter into the
notes. All events involving the patient should be described
as objectively as possible.




Document any occurrence that might affect the patient.
Only documented information is considered credible in
court. Undocumented information is considered
questionable since there is no written record of its
occurrence.
Always use current date and time with documentation. For
example, if adding a note after the fact, it can be labelled
"addendum to care" and inserted in correct chronological
order, rather than trying to insert the information on the
date of the actual occurrence.
Record actual statements of patients or other individuals
in quotes. ( )
Never leave the chart in an unprotected environment
where unauthorized individuals may read or alter the
contents.
If the patient will transfer to another institution do not
allow someone else to bring the medical chart or transfer
the patient with the chart.


Additional Dos and Donts of
Documentation
Do read what other providers have written before
providing care and before charting.
Do use flow sheets/ checklist to keep information on
patients chart.
Do write your own observations and sign over printed
name . Sign and initial every entry.
Do use only approved abbreviations.
Do use standard chart form.
Don'ts
Dont begin charting until you check the name and
identify the number on patient chart on each page.
Dont white out or erase error.
Dont squeeze in a missed entry or leave space for
someone who forgot to chart.
Dont write in a margin.
Dont use notebook , paper or pencil.
OBSOLETE TERMS SUGGESTED PHRASE
Vital signs taken Document if you were not able to
take vital signs and why.
Afebrile If the patient is febrile, support it
with subjective and objective
cues. Evaluate effectiveness of
nursing intervention of fever,
include the element of time.
Due meds/medication given Document the medicines not
given and its reason. Document
stat medicines given, its
indication and evaluate the
effectiveness.
Seen at intervals Visit patient frequently and assess
for any complication.
Conscious & coherent Patient oriented to date, time and
place.
Needs attended/kept
comfortable/kept safe
Enumerate measures done to
make patient comfortable;
verbalized needs must be also
documented and referred to
Doctors as necessary.
No complaints made/for further
management
Why document something that
never happened?
No pain Note pain level and then evaluate
patients response to
interventions done
Slept fairly/sleep well/asleep the
whole shift
If the patient has difficulty in
sleeping, document the subjective
cues, interventions done and
evaluation
*Slept for approximately 5
hours as verbalized by patient.
Walking ad lib Walks around the unit, up to the
elevator and back to room
without any discomfort.
Diuresing well Furosemide 10mg at 2:30pm
resulted in 1000ml of clear, yellow
urine.
D/C Use discharge or discontinue.
OD, OS, OU Use right eye , left eye, each
eye.
AD, AS, AU Use right ear , left ear, each
ear.
U Write unit
O.D., QD, o.d., qd Write daily
> (greater than) < (lesser than) Write greater than, lesser than
cc Write ml or milliliters
S.O. This is not an accepted
abbreviation.
MGH Not an accepted abbreviation.
Patient seen by Dr. Realiza with
discharge order given.



How should information be
documented?

Clearly with correct spelling
Comprehensively
Completely
Accurately







How to do Focus Charting or F-
DAR

Three columns usually used
in Focus Charting for
documentation:
Date and Hour, Focus, and Progress Notes.
The progress notes are organized into (D) data, (A)
action, and (R) response, referred to as DAR (third
column).

DATE/ Time
Shift
FOCUS PROGRESS NOTES
7/5/2011 8:00pm
7-3
Shift
Focus of care, this may
be:

a nursing diagnosis

a sign or a symptom

an acute change in the
condition

behavior













DATA-



ACTION-



RESPONSE-



(Focus )
Nursing Diagnosis:
Hypothermia Insomnia
Hyperthermia Hopelessness
Diarrhea Risk for nutrition imbalance
Risk for falls Risk for infection
Fatigue Risk for suicide
Fear Post trauma syndrome
Risk for poisoning Oral mucous membrane , impaired
Ineffective breathing pattern
Risk for fluid volume imbalance
Risk for fluid vol.excess
Risk for injury


(Focus )
Signs and Symptoms:

Abdominal pain, generalized Pain upon urination
Epigastric pain Persistent cough
Hypogastric pain Indigestion
Abnormal vaginal discharges Skin rashes
Backache Excessive thirst
Headache Swelling
Bloody urine Vomiting
Difficulty of breathing Numbness
Frequent urination Seizures
Difficulty in swallowing Tremors
Nausea Restlessness
(Focus)
Acute change in the condition:

Lack of appetite, nausea, vomiting
Dizziness or light headedness
Insomnia
Shortness of breath
Nosebleed
Persistent rapid pulse
General malaise
Peripheral edema (hands , feet, face )
Gradual loss of consciousness

(Focus )
Behaviour:

Feeling tired or slowed down
Restless
Irritability
Suicidal attempt
Laughing
Crying
Talking very fast
Fear
Unable to sleep / little sleep



The Data Category

The data category is like the assessment phase of the
nursing process. It is in this category that you would be
writing your assessment cues like: vital signs,
behaviors, and other observations noticed from the
patient. Both subjective and objective data are
recorded in the data category.

Ward Setting:
Subjective Objective Hooked vital signs

Example Data: (Ward)

D- Galisod ko ug ginhawa, as verbalized by the patient.
Flaring of nostrils noted, gasping for breath, bluish discolo -
ration of lips and nail beds, restless. With IVF of D5water 1
liter + 2 amps Anhydrous Theophylline regulated at
15gtts./min. at right metacarpal vein infusing well, with O2
inhalation at 4-5L /min.via nasal cannula, FBC fr. 16 attached
to urobag with urine output of 100ml. dark yellow in color.
Bp-150/90, HR-100 beats/min., RR- 30 cycles/min.,T.- 38c .

Subjective Objective Hooked vital signs

Example Data: ( ER )
ER ( upon admission) :

Subjective Objective Vital signs

D- Sakit akong tiyan, as verbalized by the patient. Pale,
with grimace face, cold clammy skin , restless, with pain scale of
6 out of 10. Bp-140/90, HR- 90beats /min., RR-21 cycles/min. T-
37c.


The Action Category

The action category reflects the planning and
implementation phase of the nursing process and includes
immediate and future nursing actions. This may include
calling the doctor, giving of STAT medication ( pain relie -
ver , antipyretic ),insertion of intravenous fluids, insertion
of foley bag catheters, nasogastric tube, endotracheal tube,
the making of lab request (CBC, Xray, CT Scan, Request for
OR),dressing of wounds, referrals (consultant,
anesthesiologist or social worker), positioning of patient,
or patient education DR. BLUE,CPR.

An example of the action for a focus of
alteration in comfort related to pain might
be:

Assessing pain every two hours, administering pain
medication every four hours as needed and
repositioning the patient every hour.

The Response Category

The response category reflects the evaluation phase of the
nursing process and describes the clients response to any
nursing and medical care.

Example: Nawala na ang sakit sa akong tiyan,as verbalized by
the patient. Bp- 120 /80.
Or Dili nako init maam, T- 37C.
Or Fever subsided from 39.5C to 37.9 C.
For follow-up CBC result (ultrasound result, xray result, or CT
scan result)
NURSING DOCUMENTATION
FOR QUALITY NURSING CARE
THE QUALITY OF INFORMATION IS
TOTALLY DEPENDENT ON THE
QUALITY OF RECORDS CREATED
AND MAINTAINED BY PEOPLE
INVOLVED
WHAT ARE THE PRINCIPLES OF
DOCUMENTATION
DOCUMENTATION

Should be SYSTEMATIC, TIMELY, and
ACCURATE and give a CLEAR ACCOUNT
of the nursing care that was provided.

Should contain COMPLETE and
ACCURATE set of INFORMATION to
facilitate effective Patient Care and its
Evaluation.
HOW DO WE DETERMINE
COMPLETENESS OF RECORDS?
It is ACCURATE if what is recorded
conforms very closely to the true
condition of activities performed.

Records should be adequate if it
sufficiently shows compliance with
acceptable standards. Entries should
be up-to-date to be reliable.
WHAT ARE THE FUNDAMENTALS OF
EFFECTIVE DOCUMENTATION?

Effective Documentation means

A. Write legibly, neatly, clearly and
readably.

B. Use proper spelling and grammar.
Misspelled words and wrong use of
grammar could lead to
misinterpretation of entries.

C. Choose terms carefully, be specific
and concise. Use of appropriate
terms to describe patients
condition.

D. Write the date and time of each
entry.
- Documenting the sequence of
events and changes in patients
condition is essential; document
as soon as possible after an
observation is made and when
care is provided.

E. Use only approved abbreviations as
these can lead to serious errors.

F. Document all observations
objectively.
- Complete factual accurate
decision will give a clear account
on patients care.
G. Correct errors by drawing a single
line and place above the line
mistaken entry, then sign above
the mistaken entry.
H. Sign all documents. Always PRINT
your complete name and affix your
signature, if possible use tro dat.
DATE/
SHIFT/
TIME

Sample 1
FOCUS DATA ACTION RESPONSE
08/24/2011
7-3 shift
9:00 AM



9:10 AM



10:00 AM


Abdominal
Pain


D-Patient verbalized sakit gyod akong tiyan, pain
scale 8 out of 10, facial grimacing, guarding behavior,
irritable, Temperature 37.4
0
C, pulse 70 beats per
minute, respiration 18 breaths per minute.----------
A-Administered Hyoscine N-butyl bromide 20 mg
Intravenously as per doctors order, encouraged and
demonstrated deep breathing exercises, placed in
semi Fowlers position with side rails up and locked.
R-Patient reports pain was relieved. Pain scale 5/10.--
-----------------------------------------Lysette Bagatua,RN
DATE/
SHIFT/
TIME

Sample 2
FOCUS DATA ACTION
RESPONSE
08/24/2011
7-3 shift
1:00 PM



1:05 PM




2:00 PM


Elevated
Body
Temperature


D-Init akong lawas as verbalized. With flushed skin
and warm to touch, Temperature 38. 9
0
C via axilla,
pulse 80 beats per minute, respiration 24 breaths
per minute, blood pressure 120/80.-----------------
A-Performed tepid sponge bath, applied ice cap on
forehead, administered Paracetamol 250mg
intravenously as per doctors order. Encouraged
adequate oral fluids intake, provided calm
environment to keep patient comfortable.---------
R-Gipaningot na ko, as verbalized, temperature
decreased to 37.2
0
C.----------------Lysette Bagatua,RN
DATE/
SHIFT/
TIME

Sample 3
FOCUS DATA ACTION RESPONSE
09/15/08
7-3 shift
9:00 AM

9:10 AM





9:20 AM


Pain at
IV Site


D-Sakit man ang lugar nga naa ang dextrose as verbalized
IV site slightly swollen and with redness noted.----------
A- Checked IV site and found beginning of signs of
infiltration. Closed and removed IV aseptically, changed the
whole system, reinserted the new set aseptically into the
distal portion of basilic vein, left arm anchored, splint
applied, regulated IVF as to the prescribed drops. Advised to
call nurse for any presence of pain.-----------------------
R-Wala na ang sakit sa akong dextrose,as verbalized--------
-------------------------------------------------------M. Omamalin,RN
DATE/
SHIFT/
TIME

Sample 4
FOCUS DATA ACTION RESPONSE
08/25/11
7-3 shift
9:10 AM






9:15 AM


ER to OR
Pre-
Operative
Assessment


D-Received from ER per stretcher with side rails up and locked with
ongoing IVF of PLR 1L. at 900ml level at left cephalic vein using IV
cannula gauge 18 regulated at 30 drops/min., with oxygen
inhalation at 3L/min. via nasal cannula, nasogastric tube attached
to drainage open bottle with bloody discharges noted, Foley Bag
Catheter connected to urobag with 100ml of tea colored urinary
output. Cold clammy skin, grimace face, gnawing abdominal pain
noted.
A-Instructed patient to do deep breathing exercise. Checked the
patency of IVF drop factor, name of patient and IVF hooked,
checked the nasogastric tube and Foley Bag Catheter if dripping
well. Reviewed and checked the patient chart if all laboratory
results were attached, surgery consent signed and availability of
surgical materials and pre operative medicines. Checked and
reviewed Operating Room checklist, jewelries, dentures, nail beds,
name tag of patient applied. All surgical and pre operative
medicines checked. BP checked 100/60, HR 92 beats/min.
Respiratory rate 21 breaths/min. Skin cleaned. ---------------------------
---------------------------------
DATE/
SHIFT/
TIME

FOCUS DATA ACTION RESPONSE
9:20 AM

9:30 AM



9:35 AM


9:45 AM
10:00 AM

1:20 PM



1:35 PM





For surgical
procedure
(explor lap)

-Transported per stretcher side rails up and locked accompanied
by circulating nurse to Operating Room table.-------------------
A-Placed comfortably on Operating Room table on supine position
both arms strapped; orientation done on Operating Room
procedures, and validated all entries in the WHO Surgical Safety
Checklist.------------------------------------------------------------------
-Skin preparation done aseptically and applied sterile drapes to
abdominal area. Surgical instruments, needles, sponges counted
and witnessed by circulating nurse, J. Lopez.---------------------
-General anesthesia induced by Dr. Evangeline S. Ruaya.-----
-Exploratory Laparotomy performed by Dr. G.Realiza with Dr. C.
Mata as Surgeons Assistant.----------------------------------------
-Surgical operation ended. All surgical instruments and supplies are
accounted and declared complete. Nasogastric tube attached to
drainage bottle and Foley Bag Catheter attached to urobag draining
well. ---------------------------------------------------------------------
-Dressing done aseptically on post operative site . Arm straps
removed.-------------------------------------------------------------

1:40 PM








-R-Responsive to stimuli and pain, with spontaneous eye opening,
BP-checked 100/60, HR-90bpm, RR-20bpm with IVF of PLR 1L
ongoing regulated at 30 drops left cephalic vein, another line PNSS
1L. at 20 drops right metacarpal vein infusing well. Accompanied
and transported to PACU per stretcher, side rails up and locked.
Endorsed to nurse K. Eguia.-----------------------------Grace Bengua,RN



DATE/
SHIFT/
TIME

FOCUS DATA ACTION RESPONSE
PACU 1:45
PM








1:50 PM




1:55 PM









D-Received patient from Operating Room per stretcher, side rails
up and locked, with on-going IVF of PLR 1L. at 200 cc level at left
cephalic vein at 30 drops infusing well, another line of PNSS 1L. at
500cc level and regulated at 200 drops/ min with nasogastric tube
attached to open drainage bottle open to drain with bloody
discharges Foley Bag Catheter connected to urobag with 200cc of
tea colored urinary output; with oxygen administered at 3L/min via
nasal cannula.---------------------------------------------------------------------
-Skin cold to touch, pale looking, chilling sensation noted.----
A-placed comfortably on bed with side rails up and locked; oxygen
administered continuously at 3L/min.; monitored blood pressure
every 15 mins. Warm blanket applied. Hot water bag cap locked
tightly applied to both upper and lower extremities post-operative;
wound checked for bleeding. Measured and recorded intake and
output. Administered Tramadol 30mg injected very slowly thru
IVTT as per Doctors order. Administered antibiotics initially after
negative skin test done as post operative order by the Doctor.
Ceftriaxone 1gm administered slowly thru IVTT. Observed for
adverse reaction of the drug. Observed for nausea and vomiting.---
------------------


DATE/
SHIFT/
TIME

FOCUS DATA ACTION RESPONSE
PACU3:35 PM


3:40PM



4:00 PM

4:15 PM







Dr. Evangeline S. Ruaya updated for patient status, BP checked
110/70, HR 92 bpm, RR 21 bpm, T- 36.5
0
C, thru text with reply
may transport to ward-------------------------------------------------
R-Dili na kaayo sakit akong samad, Mam as verbalized by the
patient. Able to move both upper and lower extremities post-
operative wound checked for bleeding; sterile dressing intact and
dry as observed.---------------------------------------------------------
A-Transported to Surgical Service, per stretcher, side rails up and
locked.-------------------------------------------------------------------------
-Endorsed to Surgical Service Ward Nurse on duty.----Kate Eguia,RN


DATE/
SHIFT/
TIME

Sample 5
FOCUS DATA ACTION RESPONSE
8/24/2011
3-11 shift
9:15 PM






9:25 PM



9:50 PM

10:00 PM



Altered
comfort
related to
post-
operative
pain



D-Sakit akong samad sa tiyan, Sir as verbalized.-----------------
Facial grimace noted, irritable, moaning noted, pain scale of 8/10,
received from PACU via stretcher with ongoing venoclysis of PLR 1L.
with 900ml level left hooked at right cephalic vein, with nasogastric
tube in place open to drain with greenish output; and indwelling
catheter in place attached to urine bag with output of 450ml
yellow tinged urine.---------------------------------------------------------
A-Placed on bed in supine position, medication record checked for
last administration of Tramadol; instructed to do deep breathing;
supported abdomen with pillow while turning to sides, abdominal
binder applied----------------------------------------------------------------
R-Sakit pa gihapon akong samad as verbalized. Still in pain as
evidenced by a pain scale of 7/10. ------------------------------------
A-Inspected dressing for discharges. Dressing dry and intact. Given
with Tramadol 50mg as PRN for pain intravenously, with blood
pressure precaution.--------------------------------------------------------
DATE/
SHIFT/
TIME

Sample 5
FOCUS DATA ACTION RESPONSE

10:35 PM









R-Arang-arang na akong pamati, Sir as verbalized, pain has
reduced as evidenced by a pain scale of 4/10. Patient understood
instructions and seen performing deep breathing. Endorsed to 11-7
shift for continuity of care.------------------------------------M. Galvez,RN


DATE/
SHIFT/
TIME

Sample 6
FOCUS DATA ACTION RESPONSE
08/23/2011
7-3 shift
7:00 AM


7:30 AM



7:35 AM




8:00 AM





Altered
comfort:
Pain related
to post
Caesarean
Section
wound


D-Received on bed with on-going intravenous fluid of D
5
LR 1
liter at 550ml level infusing well on right cephalic vein at
20gtts/min-----------------------------------------------------------
Sakit akong samad, as verbalized. With pain scale of 8/10
BP of 130/100, pulse 105 b/min., T-37.3
0
C; restless, guarding
behavior over incision site, facial grimace, profuse sweating,
pale looking.---------------------------------------------------------
A-Incision site checked with no foul smell and no discharges;
wound dressing intact and dry; repositioned to Semi-Fowlers
position. Encouraged and demonstrated relaxation
techniques such as deep breathing. Applied abdominal
binder.-----------------------------------------------------------------
R-Sakit pa gihapon akong samad as verbalized; pain scale
of 7/10, BP 130/90------------------------------------David Silva,RN


DATE/
SHIFT/
TIME

Sample 7
FOCUS DATA ACTION RESPONSE
08/23/2011
3-11 shift
3:00 PM
4:00 PM



4:20 PM

4:45 PM
4:50 PM


5:00 PM



Anxiety
related to
scheduled
surgery


D-Received with IVF of D
5
LR 50ml at KVO at left cephalic vein.---
Mahadlok ko sa operasyon nako unya, as verbalized. Asked
questions repeatedly regarding surgery. Cold, clammy skin, looks
worried, pale-looking. BP-150/90, HR-128 b/min, RR-24 c/min,
T-36
0
C.-------------------------------------------------------------------------
A-Family members encouraged to stay with the patient. Referred to
Dr. Lee for the re-explanation of the surgical procedure.
Encouraged to verbalize feelings. Consent signed by the patient
Assisted Dr. Lee during rounds. Procurement of materials for
surgery followed-up. Provided perioperative health teachings.
Allowed to ask questions and answers provided.-------------------
R-Nakasabot na ko sa operasyon. Wala na ko nahadlok. Gipapalit
na nako ang mga gamit sa operasyon as verbalized. Appears
relaxed and skin is warm to touch. T-36.5
0
C, RR- 18 cpm, HR-89
bpm, BP-120/90, -------------------------------------------------Ira Lakian,RN



DATE/
SHIFT/
TIME

Sample 8
FOCUS DATA ACTION RESPONSE
8/25/2011
7-3 shift
6:50 AM






6:55 AM


6:57 AM







Abdominal
pain Scale
of 9/10


D-Nadisgrasya siya Maam, gasakit iyang tiyan as verbalized by
wife. Brought in per stretcher, pale and cold clammy skin noted, in
severe pain scale of 9/10, in moderate respiratory distress bluish
contusion 6cm observed at the right temporo-parietal and in the
left parietal areas. Abdominal pain noted as evidenced by grimaced
face, with a board-like abdomen on palpation, slightly restless, GCS
15/15, T-36
0
C P-110 beats/min R-42 breaths/min BP-50/30.-----
Placed on bed with side rails up and locked, with head of bed
elevated to 30
0
angle, 0
2
inhalation administered at 3-4 L/min via
nasal cannula. Ice pack applied to contusions. ---------------------
-Seen and examined by Dr. Genesis Realiza, consent for admission
signed by wife. Started with venoclysis of PLR 1L at fast drip for the
first 500ml hooked at the left cephalic vein using IV cannula gauge
18, then regulated to 60 gtts/min. Another line initiated at the right
metacarpal vein with PLNSS 1L using blood transfusion set
regulated at 15gtts/min.-------------------------------------------------

DATE/
SHIFT/
TIME


FOCUS DATA ACTION RESPONSE
7:00 AM

7:30 AM



7:50 AM







R-BP rechecked 80/40 P-120 beats/min R-44 breaths/min, sakit
kayo akong tiyan Maam, as verbalized .--------------------------------
A-Ketorolac 30mg IVTT given as ordered stat. Brought to the X-ray
and accompanied by nurse M. Omamalin per stretcher with side
rails up and locked for abdominal x-ray flat plate and upright view;
stat CBC, BT taken by Medical Technologist Antonio Lagod. ------
-X-ray plates and CBC results seen by Dr. Realiza, orders given.
Scheduled for an emergency exploratory laparotomy, consent for
surgery and induction of anesthesia signed by wife, after proper
explanation of pre-operative and post-operative procedure done
by Dr. Realiza. Nasogastric tube Fr.16 inserted at the right nostril by
Dr. Realiza and open to drain; Foley Bag Catheter Fr.16 inserted
aseptically by nurse M. Omamalin and attached to urobag with tea
colored urine output at 150ml level. Instructed the wife to secure 2
units of blood of patients blood type A
+
for possible surgical
operative use. OR nurse Mr. Mark Galvez and anesthesiologist Dr.
Evangeline Ruaya informed of the procedure. ------------------------

DATE/
SHIFT/
TIME


FOCUS DATA ACTION RESPONSE
8:20 AM


8:55 AM


9:15 AM






Cefuroxime 1.5gm administered as loading dose via IVTT after a
negative skin test and no adverse drug reaction noted after 30
minutes.-------------------------------------------------------------------------
R- Prescribed drugs and surgical supplies already available. Still
with abdominal pain, scale of 8/10, moderate bloody discharges in
NGT, T-36.8
0
C, PR-12 beats/m, RR-40 breaths/min, BP-90/60---
A- Transported to OR per stretcher with side rails up and locked and
complete drugs and surgical supplies needed.----------Nesle Lim, RN

DATE/
SHIFT/
TIME

Sample 9
FOCUS DATA ACTION RESPONSE
7/23/2011
7-3 shift
10:00 AM


10:15 AM



11:00 AM





Constipation



D-Maam, tulo na kaadlaw wala ko nakalibang as verbalized.
Stomach distended, hypoactive bowel sound upon auscultation
noted; irritable, T-7.80C, PR-80 bpm, RR-28 bpm BP-130/90.----
A-Given suppository per Doctors order and provided privacy;
advised to increase fluid intake and eat foods high in fiber like
green leafy vegetables (kangkong, pechay, malunggay) and fruits
(papaya, pineapple), encouraged mobility------------------------------
R- Able to defecate and felt comfortable.------------------Belia Bohol,RN

DATE/
SHIFT/
TIME

Sample 10
FOCUS DATA ACTION RESPONSE
8/23/2011
3-11 shift
3:05 PM


3:10 PM


3:15 PM






6:00 PM


11:00 PM



Ineffective
air way
clearance
related to
excessive
mucous
secretions



D-Naglisod ko og ginhawa as verbalized, with labored breathing,
productive cough with mucopurulent seceretions, RR-30 bpm, with
slight flaring of nostrils-----------------------------------------------------
A-Lowered the bed, placed on high Fowlers position with side rails
up and locked; administered Oxygen at 3 liters per minute;
loosened clothing and made comfortable-----------------------------
-Referred to Dr. Maurice Montecillo. Orders given; nebulized with
1 nebule as ordered; PLR 1L started at 15gtts/min at right
metacarpal vein infusing well; demonstrated back tapping after
nebulization, encouraged and demonstrated deep breathing and
coughing exercises, encouraged increase oral fluids intake to 8-10
glasses per day; provided a calm and well ventilated environment
free from allergen.-----------------------------------------------------------
R-Verbalized ease of breathing and tolerable cough. Understanding
of instructions noted through demonstration of proper deep
breathing and coughing exercises. --------------------------------------
-Latest RR-24 cycles/min and endorsed to next shift.---Peter Soro,RN
DATE/
SHIFT/
TIME

Sample 11
FOCUS DATA ACTION RESPONSE
8/25/2011
7-3 shift
11:50AM


12:00 Noon



12:05 PM




12:15 PM




Elevated
blood
pressure



Admitted this 52 y.o. female with complaints of body malaise and
numbness at left side of the body with onset of headache prior to
admission.---------------------------------------------------------------------
D- Lain iyang pamati, bas verbalized by the daughter, Maria
Realiza. Patient is lethargic with facial drooping noted, with slurred
speech, with initial vital signs of BP 180/100, HR-132 bpm T-37.2
0
C
per axilla.------------------------------------------------------------------------
A-Ushered to ER bed and positioned to semi-Fowler, side rails up
and locked, initiated with humidified oxygen support at 3-4 liters
per minute via nasal cannula. Consent to care signed by the
daughter, Maria Realiza, Referred to resident on duty Dr. Lucy Itok
about this admission--------------------------------------------------------
-Assisted Dr. Itok on her bedside assessment. Orders made and
carried out properly. Plain NSS 1L inserted aseptically as venoclysis
at 20 gtts/minute at left metacarpal vein; Captopril 25mg. given
sublingual (not to chew nor crush the tablets) Furosemide 40mg.
given intravenously STAT. All are as ordered. -------------------------
DATE/
SHIFT/
TIME


FOCUS DATA ACTION RESPONSE
12:25 PM

12:30 PM








2:00 PM



-CBC, BUN, CREA, Lipid Profile, FBS requests sent to laboratory. EKG
taken and referred to Dr. Itok for interpretation---------------------
-Informed the watcher about ICU admission. Consent for ICU
admission signed by daughter, Maria Realiza. ICU informed about
this admission. Request for Plain Brain CT Scan and chest X-Ray AP
view handed over to watcher for payment at Cashiers Office.
Referred to neurosurgeon, Dr. Jones for evaluation and
management thru phone call and responded will see the patient
later. CT Scan and Chest X-Ray taken as accompanied by ER
Nurse, Mark Galvez, and transported to ICU per stretcher with side
rails up and locked.----------------------------------------------------------
-Endorsed to ICU Nurse on duty, Rhoda Ordinaria.-----------------------
-----------------------------------------------------------------Gerry Zamoras,RN

DATE/
SHIFT/
TIME

Sample 12
FOCUS DATA ACTION RESPONSE
8/25/2011
3-11 shift
3:00 PM







3:10 PM



4:00 PM


Elevated
Blood
Pressure
160/90



D-Appears lethargic , cold and clammy skin noted, flaccid muscle
tone on the left side of the body; right facial drooping noted,
slurred speech, able to move all extremities per command but with
left hemiparesis; eye opening is appreciated upon name calling;
anisocoric, pupillary size of 6mm at right eye and 3-4mm at left
eye; right pupil is sluggishly reactive to light while left pupil is
briskly reactive to light accommodation. BP-160/90, HR-98 bpm,
RR-23 cpm, T-37
0
C.--------------------------------------------------------
A-Placed on bed with side rails up and locked; head of bed
elevated at 30
0
angle; oxygen inhalation administered; hooked to
cardiac monitor and pulse oximeter attached; visited by Medtech
for blood extraction, CBC, BUN, CREA.--------------------------------
-Visited by Dr. Jones. Orders given and carried out properly. Serum
Na
+
and K
+
determination request sent to laboratory; 3-way urinary
catheter Fr.16 inserted aseptically and obtained urine specimen
and brought to laboratory for urinalysis then catheter attached to
urine bag.---------------------------------------------------------------------
DATE/
SHIFT/
TIME


FOCUS DATA ACTION RESPONSE
4:15 PM





5:15 PM

6:30 PM
9:30 PM

10:30 PM






-Mannitol 20% 500ml given 150ml at fast drip using large bore
needle gauge 19; Nicardipine in 80ml of D
5
Water via soluset at
initial rate of 100 microdrips per minute and titrated by increments
of 5 microdrips per minute every 15 minutes to maintain systolic
BP range of 120-150 as ordered. Arterial blood specimen extraction
done aseptically by Dr. Jones and sent to laboratory.------------
-Laboratory results for CBC, S CREA, BUN and ABG in. Relayed to Dr.
Jones thru SMS, updated patients status and replied ok thanks---
R-BP rechecked 140/80.---------------------------------------------------
A-Visited patient and encouraged verbalization of any medical
problems such as headache. Continuous BP monitoring done.
R-Last BP 140/80 for FBS and lipid profile determination in AM.
Endorsed to next shift Nurse J. Bataga.------------Rhoda Ordinaria,RN
DATE/
SHIFT/
TIME


FOCUS DATA ACTION RESPONSE
8/25/2011
11-7 shift
11:00 PM













12:00 MN





D-Received on bed awake with head of bed at 30
0
angle elevation,
with ongoing IVF of PNSS 1L hooked at left metacarpal vein flowing
at 20 drops/min infusing well, with 160ml level left with starting
dose of Nicardipine Drip (80ml D
5
W + 20mg) at 10 microdrips/min.
rate. With ongoing humidified 0
2
inhalation at 3-4 l/min. via nasal
cannula, with indwelling urinary catheter attached to urine bag,
patent and draining well; contains bright yellow urine with
approximately 150ml in volume. With multiparameter cardiac
monitor attachment, right facial area drooped. As noted, with
pupillary size of right eye 5-6mm, left eye 3-4mm, right pupil is
sluggishly reactive to light, while left pupil is briskly reactive to light
accommodation, able to move all extremities per command,
slurred speech, with spontaneous eye opening. -------------------
D-Labad man akong ulo Maam as verbalized while pointing at
right parietal area of the head, facial grimace is noted, irritable
with pain scale of 7/10; BP 160/100, HR-119bpm, RR-24cpm, T-
37.3
0
C, 02 sat 97%.---------------------------------------------------------
DATE/
SHIFT/
TIME


FOCUS DATA ACTION RESPONSE
12:10 AM
12:13 AM
12:15 AM



2:00 AM

3:00 AM
6:45 AM



A-Dim light provided, applied ice pack over the right parietal area.--
-Referred to Dr. Jones thru phone call, orders made and carried out
properly. STAT dose of Tramadol 25mg given slow IV as ordered,
STAT dose of Mannitol 20% 100ml given via IV fast drip as ordered.
Unnecessary disturbance avoided and promoted a cool, calm and
quite non stimulating environment.----------------------------------
R-Nawala-wala na ang labad sa akong ulo Maam as verbalized by
patient, pain scale of 4/10. -----------------------------------------------
A-Seen soundly asleep and undisturbed.-----------------------------
R-Verbalized to be free from pain; Still for lipid profile and FBS
determination.------------------------------------------Rhoda Ordinaria,RN

DATE/
SHIFT/
TIME


FOCUS DATA ACTION RESPONSE
8/26/2011
7-3 shift
7:30 AM











7:45 AM

7:50 AM

7:55 AM






D-Received on bed in supine position at 30
0
angle head of bed
elevation. With ongoing IVF of PNSS 1L at 20 drops/min at left
metacarpal vein with 520 fluid level left, with side drips of 20ml
Nicardipine and 80ml of D
5
W via soluset at 10 drips/min; with
humidified oxygen inhalation at 3-4 liters per minute via nasal
cannula with indwelling urinary catheter attached to urine bag with
yellow colored urine at approximately 200ml. Appears conscious
with spontaneous eye opening and pupillary size of 5mm sluggishly
reactive to light at right eye and 3mm briskly reactive to light at left
eye, patient show body weakness but able to move all extremities
per command, with slurred speech as verbal response. Initial vital
signs of BP-130/90, HR-82 bpm, RR-20 cpm, T-36.5
0
C.-----------
A-Oatmeal diet was served to the patient and able to consumed 8
spoonfuls of the food. On Aspiration Precaution; assisted patient
on sitting position; assisted Dr. Itok during visit with given order of
may transfer to room of choice if okay with Dr. Jones. Informed
Dr. Jones thru telephone with telephone order of okay for me to
transfer to ward. ----------------------------------------------------------
DATE/
SHIFT/
TIME


FOCUS DATA ACTION RESPONSE
7:40 AM
7:48 Am
7:52 AM

8:00 AM
8:15 AM

8:25 AM

8:28 AM




9:00 AM

9:15 AM








Knowledge
deficit
related to
disease
process,
lifestyle

-Visited on bed and encouraged to verbalize feelings. Positioned to
semi-fowlers and maintained safety measures by placing side rails
up and locked. Informed the daughter regarding the transfer and
given options regarding various accommodations. ---------------
Family member opted to be accommodated at suite room.
Informed station nurse on duty thru phone call on patients
transfer.------------------------------------------------------------------------
D-Maam, unsa kaayo ang ginadili nakong kan-on? as asked by
patient. Appears confused and worried.------------------------------
A-Explained the importance of lifestyle and diet modification and
advantages of compliance. Instructed also to avoid taking alcohol
and smoking. Encouraged patient to limit intake of high sodium,
high fat and high cholesterol diet, instead encouraged increased
intake of green leafy vegetables and high fiber diet.---------------
R-Dili nako manigarilyo og mu-inon og beer karon Maam. Ako na
pud limitahan akong pagkaon og mga tambok og asgad na
pagkaon as verbalized. Seen patient smiling and comfortable in
bed.-----------------------------------------------------------------------------
DATE/
SHIFT/
TIME


FOCUS DATA ACTION RESPONSE
9:28 AM




10:00 AM






11:15 Am


11:23 AM









A-Assisted Dr. Jones during visit. For referral to physical therapist
for further management as ordered. Request form sent to rehab
unit by the nursing attendant Ms. Nayal. Take home medication
was ordered and carried out correctly at discharge instruction
sheet.---------------------------------------------------------------------------
A-Assisted family member during visiting hour. Health teaching was
imparted on the importance of constant monitoring of blood
pressure, the compliance of medication and the importance of
early consultation for any health care related problems. Take home
medications discussed and explained to the patient and the
daughter. Reminded also regarding the patients next scheduled
visit on September 21, 2011 at 8am, OPD.---------------------------
R-Patient able to enumerate all take home medications with
correct dosage and timing. Patients daughter verbalized
Nakasabot nako Maam-------------------------------------------------
A-Received phone call from ward stating that the room is ready for
transfer.--------------------------------------------------- Rhoda Ordinaria,RN
DATE/
SHIFT/
TIME


FOCUS DATA ACTION RESPONSE
11:25 AM




11:40 AM




11:57 AM
Pre-
assessment
upon patient
transfer







D-Awake and responsive, free form any pain, still slurred speech as
verbal response, body weakness still noted but able to move all
extremities at times without any command. Pretransport vital signs
are BP-130/90, HR-76 bpm, RR-18 cardiac per minute, T-37
0
C per
axilla.---------------------------------------------------------------------------
A-Transported to Suite Room per stretcher with side rails up and
locked. Aided throughout the transport.----------------------------
-Informed attending physicians Dr. Itok and Dr. Jones that patient
was transferred at Suite Room with room number 307 thru phone
call.------------------------------------------------------------------------------
R-Still awaiting to be seen by Physical Therapist for daily range of
motion exercises. Discharge instruction sheet was attached to chart
and to be given to the family prior to discharge. Endorsed to nurse
on duty.----------------------------------------------------Rhoda Ordinaria,RN
DATE/
SHIFT/
TIME

Sample 13
FOCUS DATA ACTION RESPONSE
8/25/2011
6-2 shift
6:00 AM



6:05 AM



6:10 AM




7:08 AM



Hemodialysis
with
pulmonary
congestion







Received from medical ward per wheelchair with 0
2
inhalation on
going at 5-6L/ml via nasal cannula.-------------------------------------
D-Naglisod ko ug ginhawa Maam as verbalized; oriented to
place, date and time; labored breathing noted with flaring of
nostrils; weight gain of 4.0kgs; BP-150/100; with heplock on right
metacarpal vein.-------------------------------------------------------------
A-Assisted comfortably to the hemodialysis chair; consent for
hemodialysis signed by wife; skin preparation of arteriovenous
fistula access done aseptically and with positive thrill upon
palpation; cannulated with ease.---------------------------------------
Hemodialysis started scheduled for 4 hours with ultrafiltration goal
of 4.0 liters and ultrafiltration rate of 250-350 ml/min; 2000 units
of regular heparin given as IV bolus and 1000 units every hour
thereafter as anticoagulant;monitored for signs of hypotension;
BP/HR monitoring done every 15 mins.-------------------------------
visited by Dr. G. Doble with order made to discharge patient after
hemodialysis once cleared; ward nurse informed of the discharge
order to facilitate for the billing and discharge clearance of the
patient.-------------------------------------------------------------------------
DATE/
SHIFT/
TIME


FOCUS DATA ACTION RESPONSE
9:00 AM


9:05 AM





10:10 AM




10:40 AM



Health
teaching
with
discharge
instructions



R-Puede na ko dili mag-0
2
Maam kay mayo na ang akong
ginhawa, patient verbalized; looks relaxed and normal breathing
pattern was observed.-----------------------------------------------------
A-Reinforced teaching given to both patient and wife to limit oral
fluid intake to 700ml/day to avoid dyspneic attack; instructed to
have a low-salt, low fat and low purine diet; reminded patient of
saving left arm to prevent potential damage to access site for
future use.---------------------------------------------------------------------
-Encouraged patient to come on his next hemodialysis schedule.
R-Mag-control na ko sa akong imnon ug magbantay na ko kung
unsa akong kaunon, as verbalized by patient HD completed;
cannula removed and pressure dressing is applied; heplock
removed and dressed; assisted patient to upright position and 5
mins. to prevent orthostatic hypotension. --------------------------
-Discharged ambulatory with assistance to vehicle with clearance in
fair condition.-----------------------------------------------Prisca Nalzaro,RN