revised focus dar method

8/2/2019 Revised Focus DAR Method

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The Focus Charting System is the

accepted documentation system at

Windsor Regional Hospital.

Focus Charting


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Flexible enough to adapt to any clinical practice

setting and promotes interdisciplinary

documentation

Centers on the nursing process, includingassessment, planning, implementation and

evaluation Information is easy to find because data is

organized by the focus. It promotes communication between all care

team members.

Advantages of FocusCharting


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Encourages regular documentation of patient

responses to care Helps organize document so that it is concise

and precise Can be easily adapted to computer based

documentation systems

Advantages of FocusCharting


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The Focus: It describes the focus of actions

DAR format: Is the structure used to document

patient assessment, care interventions or actions and

patient responses to the actions or care

Focus Charting Combines


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Focus Lists

Progress Notes

Flow Sheets Care Plans

The Focus System Uses:


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A focus may also be written in the format of a nursing diagnosis

Refers To Example

A patient behaviour Inability to ambulate

An acute change in the patients conditionLoss of consciousness

or increase in blood pressure

A significant event in the patients therapy Surgery

A special patient need Discharge planning need

Hypotension, or chest painA sign or symptom

Developing the Focus


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A FOCUS LIST sheet is used as an index or quick reference

for what you will find in the progress notes. All disciplinesshould record on the focus list

The focus is numbered in order

that they are listed

Document the focus

The date the focus is identified

is indicated in the active

column

The dates are entered if the

focus is resolved or resinstated

The discipline entering the focus

should identify themselves.

1

2

Inability to

ambulateChest pain Nursing

Nursing, PT11/12/01

11/12/01

The Focus List


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Focus Lists must be regularly updated

and expanded as the patients

condition changesAt discharge, focus list needs to be

checked to ensure that all the

foci have been addressed and / or

resolved.

The Focus List

Additional Information about the Focus ListAdditional Information about the Focus List


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All disciplines should have a

plan of care.

Care Plans are included either

as a standard nursing

care plan

or as an entry in the

progress notes

under the A. Standardized care plans should

be activated with the patient

and/or significant othersin ut in order to make it

Once a focus has been identified, a plan of care needsOnce a focus has been identified, a plan of care needsto be documented.to be documented.

The Use of Care Plans


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There are numerous pre-printedflow sheets available at WRH

These are helpful in accurately

and concisely documenting

routine and frequently collected

data Use flow sheets whenever it is

logical and helpful to do so. For

example: Any documentation

which is required on a regular

basis by hospital policy or

standard. Any nursing care activity which

is provided on a regular basis

i.e. activities of daily living

Flow Sheets


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Examples of Flow sheets are:Examples of Flow sheets are: vital signs record, medication record, intake and output,

post op flow sheet, wound assessment record

Flow Sheets


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All flow sheets must becorrectly dated and

must contain the

patients

name on both sides.

All entries on the flowsheets must be initialed

(no use of check marks)

by the person who

assesses or provides

the care and must have

initials with full signature

on a master copy. Any variances from

normal should be

recorded in DAR format

01/12/02

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Flow Sheets


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Dos Charting on the flow sheets should be

done as the care is delivered

or patient data observed

Develop assessment parameters that

have meaning to everyone for example:Check abd incision q2h for drainage,

redness, tenderness versus check

incision

Make the flow sheets reflect the care

needs of the patient

Be concise

Analysis of the trends in the patient data

to assess if there are changes in the

patients condition

Write legibly

Dont leave blanks

Dont squeeze data into

spaces provided. If not

adequate space it isnecessary to progress

note

Double document in

various parts of the

charting system

Donts

Flow Sheets


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Are Used to: Provide detail to data in a flow sheet. Document patient response to care.

Record an unusual or unexpected event.record changes in patient condition and

notification to the MD Describe the status of the patient at the time of

admission, transfer from one nursing unit toanother, or at the time of discharge.

Progress Notes


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When writing progress notes you shouldinclude information about:

Progress Notes

The details about the patients condition

(assessment data)

The interventions or nursing actionsimplemented and their effectiveness

The patients response to care


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Notes are chronologicallyentered. The date and

time is documented in the

columns provided. The

time and date you are

actually writing the note is

used.

The service or discipline

writing the note is

recorded

When starting a note the focus is

documented first

In focus charting the

structure of the progress

note that follows the focus

uses a DAR outline: Data,

Action Response

Nov. 12/01 1400 O.T. #1 -Swollen painful left hand.----------------

D - Assessment done as per referral-----------

Left hand swollen. Digits in extension.---Painful to passive ranging.---------------

A - Discussed splint use and benefits with Pt.

Splint molded. On-off schedule developed.

R - Pt. concerned splint will be painful------

------------------------------K. Smith O.T.

How to Complete a Progress Note


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Is an acronym

Data - subjective & objective patient assessment data thatsupports the Focus Statement or describes observations of a

significant event

Action - immediate or future actions or plans of action

or care based on the evaluation of assessment data

Response - the patient response to the action taken.

How to Complete a Progress Note


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The Response may not need to be immediately charted. There may

not be an immediate response, therefore, only Data and Action may

be charted

Eventually, there should be a Response entered to that action taken

Progress notes must have a

signature after each entry

There may be more than one

focus that requires charting at

one time

D a t e T i m eJ u n e2 2 2 22 2 2 2 N r s g . W o u n d D r e s s i n g

1 1 1 1

D - M o d e r a t e a m o u n t o f p u r u l e n t , f o u li n c i s i o n n o t e d . S u t u r e l i n e r e d a n d s w o2 2 2c o m p l a i n i n g o f p a i n a t t h e s i t e . - - - - - - - - - -A - D r . B . J o n e s n o t i f i e d a n d i n f o r m e dr e c e i v e d . A n a l g e s i c a n d a n t i p y r e t i c g i vt a k e n a n d s e n t t o L a b . W o u n d c l e a n s ed r y d r s g . A p p l i e d . - - - - - - - - - - - - - - - - - - - - - - - - - - - -- - - - - - - - - - - - - - - - - - - - - -R - T . P a t i e n t s t a t e s i n c i s i o n a l p a i n i1 1a n d i n t a c t , n o d i s c h a r g e n o t e d . A n t i b i o- - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - -

Joan Smith R.N.

Joan Smith R.N.

Progress Notes


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Write patient progress notes only when necessary.The goal is to minimize duplication of information and

to save time.

Date Time22 June 98 1500

Nrsg.#1 pneumonia

D - pt. c/o of chest pain on inspiration, fatigue.T-39.5 at 1515, wheezy breath sounds, productivecough for purulent tenacious sputum. IV infusing.A - 02 at 3 litres, chest x-ray this am, sputumfor C&S referral for chest physio. Tylenol ii for

elevated temp at 1520. Fluids encouraged.R-T @1620 - 38---------------------Amy Nurse, RPN

Progress Notes


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Objective Precise

Specific Thorough

Progress notes can be improved bychoosing language which is:

Focus Charting Dos and Donts

Inconsistencies in documentation can leave you and the health care

facility open to accusations of incompetence.A medical record containing inconsistencies can be difficult to defend

in court. DO NOT use words like confused, uncooperative and depressed.

These words may be interpreted in different ways and are not specific

in accurately describing the patient


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Eats poorly

Patient confused

Uncooperative

Patient complaining of pain

Good day

Diuresing well

Walking ad lib

Ate 1/2 the meal and drank 80 ml fluid

Patient unable to recognize family

Refuses to assist with am care

Complaining of constant, sharp RUQabd. Pain

Patient states has been pain free

without medication and still able to

complete activities of daily living

Lasix 10 mg IV at 1430 resulted in

1000 ml of clear, yellow urine.

Walks around the unit, up to the elevator

and back to room without any discomfort

Focus Charting Dos and Donts


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Be FactualBe Factual

Be SpecificBe Specific

Be PreciseBe Precise

Be ThoroughBe Thorough

Be FactualBe Factual

Be SpecificBe Specific

Be PreciseBe Precise

Be ThoroughBe Thorough

In Summary

Avoid Summarizing or using Value

Judgements

revised focus dar method

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