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FOCUS CHARTING Focus charting is process oriented and patient centered.

It uses the nursing process to organize documentation of care. The typical focus record also incorporates a flow sheet for documenting daily interventions and treatments. DAR construct is use which stands for DATA, ACTI !,R"#$ !#". DATA%su&'ective(o&'ective information that supports the documented focus or descri&es o&servations at the time of significant event. ACTI !% immediate or future nursing, action &ased upon the assessment(evaluation of the patient)s condition. R"#$ !#"%provides description of the patient)s response to any part of the nursing care plan. The * categories may &e used singly or together to document data, activities or care planning +#"#, fle-i&le and can &e adapted to virtually any clinical setting. Advantages, .. 1. *. 2. 4. 5. The term /Focus0 is &roader and more positive than the term /$ro&lem0. !urses may find it easier to identify and to document potential pro&lems that are the focus of their nursing actions. The F C+# statement at its highest level is a nursing diagnosis. The focus construct of DAR is fle-i&le and provides cues and direction for recording of the nursing process. $atient care notes are inde-ed according to the focus of care la&el to ma3e information easy to locate. Time is save &y not having to refer to several sections of the chart in order to ma3e different entries. "asily used and understood &y other health care practitioners.

Disadvantages, .. +sing the action construct can &e confusing. 67ust reflect what was done and what will &e done. 1. 8a&el used in focus column may not &e consistent with the terminology in the care plan. To provide a unified format, the term Focus appears as column heading on &oth the care plan and progress notes. Data correlate with nursing assessment and history ta3ing. Action are the implementation and intervention. Response can &e patient evaluation. "nter the nursing diagnosis, a pro&lem that re9uires monitoring a patient concern, patient &ehavior or a defining characteristics6 of a nursing diagnosis: in the F C+# column.

;"!"RA8 C !C"$T I! D C+7"!TI!; <= F C+# 7 D" .. 1. *. 2. 4. rganize roles according to DATA, ACTI !, R"#$ !#" categories. DATA category includes the su&'ective and o&'ective information that correlate to the stated focus 6nursing diagnosis, patient &ehavior, patient status, signs and symptom or significant events, patient concern:. The ACTI ! category includes the actual planned and(or implemented nursing interventions. Includes immediate nursing, plans for nursing actions. The R"#$ !#" category includes summarizing statements of the patient)s response to nursing interventions and medical care. The DAR construct may &e entered in any order. #ome entries may reflect all three construct, others only one or two of them.