Focus Charting

FOCUS CHARTING
OR
F-DAR CHARTING
It is intended to make the client
and client concerns and
strengths the focus of care. It is a
method of organizing health
information in an individual’s
record. It is also a systematic
approach to documentation.
FOCUS CHARTING PARTS
Three columns are usually used in Focus Charting for
documentation:
 Date/Hour
 Focus
 Progress Notes
The Progress Notes are organized into (D) data, (A) action, and (R)
response, which is referred to DAR as third column.
DATE FOCUS DATA, ACTION &
/SHIFT/TIME RESPONSE
03/03/2019 D > __________________________
7AM-7PM __________________________
__________________________
9:00AM ___________________________
THE PROGRESS NOTES
FOCUS
The focus might be a nursing
diagnosis, patient’s problem,
change in patient's condition, or
any significant event.
Nursing Diagnosis
 It is a clinical judgment about individual, family, or
community experiences/responses to actual or potential
health problems/life processes.
 It is developed based on data obtained during the nursing
assessment, it is the “label” when nurses assign meaning
to collected data appropriately labeled with NANDA-
approved nursing diagnosis.
 refers to one of many diagnoses in the classification system
established and approved by NANDA.
 It is based upon the response of the patient to the
medical condition. It is called a ‘nursing diagnosis’
because these are matters that hold a distinct and
precise action that is associated with what nurses have
autonomy to take action about with a specific disease or
condition. This includes anything that is a physical,
mental, and spiritual type of response. Hence, a nursing
diagnosis is focused on care.
Comparison between Medical and
Nursing Diagnosis
Medical diagnosis is made by the physician or advance
health care practitioner that deals more with the
disease, medical condition, or pathological state only a
practitioner can treat. Moreover, through experience
and know-how, the specific and precise clinical entity
that might be the possible cause of the illness will then
be undertaken by the doctor, therefore, providing the
proper medication that would cure the illness.
The medical diagnosis normally does not change.
Nurses are required to follow the physician’s orders
and carry out prescribed treatments and therapies.
TYPES OF NURSING
DIAGNOSIS
Problem Nursing Diagnosis
A problem diagnosis (or also called actual
diagnosis) is a client problem that is present at
the time of the nursing assessment. These
diagnoses are based on the presence of
associated signs and symptoms. Examples:
Ineffective Breathing Pattern and Anxiety, Acute
Pain, and Impaired Skin Integrity.
Risk Nursing Diagnosis
A risk nursing diagnosis is a clinical judgment that a
problem does not exist, but the presence of risk factors
indicates that a problem is likely to develop unless nurses
intervene. For example, all people admitted to a hospital
have some possibility of acquiring an infection; however, a
client with diabetes or a compromised immune system is
at higher risk than others. Therefore, the nurse would
appropriately use the label Risk for Infection to describe
the client’s health status.
Wellness Diagnosis
Wellness Diagnoses (or also called health
promotion diagnosis) describe human responses
to levels of wellness in an individual, family or
community that have a readiness for
enhancement. Examples of wellness diagnosis
would be Readiness for Enhanced Spiritual Well
Being or Readiness for Enhanced Family Coping.
SYNDROME DIAGNOSIS
A syndrome diagnosis is associated with a
cluster of problem or risk nursing diagnoses that
are predicted to present because of a certain
situation or event. An example is Rape Trauma
Syndrome.
POSSIBLE NURSING DIAGNOSIS
Are statements describing a suspected problem
for which additional data are needed to confirm or
rule out the suspected problem. A possible
nursing diagnosis also provides the nurse with the
ability to communicate with other nurses that a
diagnosis may be present but additional data
collection is indicated to rule out or confirm the
diagnosis. Examples include Possible Chronic Low
Self-Esteem, Possible Social Isolation.
How to Write a
Nursing Diagnosis?
Nursing diagnostic statements describe
the health status of an individual and the
factors that have contributed to the
status. Diagnostic statements can
be one-part, two-part, or three-
part statements.
One-Part Nursing Diagnosis
Statement
Wellness nursing diagnoses are written as one-part
statements because related factors are always the
same: motivated to achieve a higher level of wellness.
Syndrome diagnoses also have no related factors.
Examples include:
 Readiness for Enhance Breastfeeding
 Readiness for Enhanced Coping
 Rape Trauma Syndrome
Two-Part Nursing Diagnosis
Statement
Risk and possible nursing diagnoses have two-part statements: the
first part is the diagnostic label and the second is the validation for
a risk nursing diagnosis or the presence of risk factors. It’s not
possible to have a third part for risk or possible diagnoses because
signs and symptoms do not exist. Examples include:
 Risk for Infection related to compromised host defenses

 Risk for Injury related to abnormal blood profile
 Possible Social Isolation related to unknown etiology
Three-part Nursing Diagnosis
Statement
An actual or problem nursing diagnosis have three-part
statements: diagnostic label, contributing factor (“related to”),
and signs and symptoms (“as evidenced by”). Three-part nursing
diagnosis statement is also called the PES format which includes
the Problem, Etiology, and Signs and Symptoms. Examples
include:
 Impaired Physical Mobility related
to decreased muscle control as evidenced by inability to
control lower extremities.
 Acute Pain related to tissue ischemia as evidenced by
statement of “I feel severe pain on my chest!”

Focus Charting

Uploaded by

Copyright:

Available Formats

Focus Charting

Uploaded by

Document Information

Original Title

Copyright

Available Formats

Share this document

Share or Embed Document

Sharing Options

Did you find this document useful?

Is this content inappropriate?

Copyright:

Available Formats

Focus Charting

Uploaded by

Copyright:

Available Formats

FOCUS CHARTING

 Risk for Infection related to compromised host defenses

You might also like