In the first video (see http://youtu.be/1V6PAFHOJis) the importance of clear and accurate documentation was outlined along with nursing responsibilities. In this video DEAR focus charting will be explained. Remember that there are many types of charting that meet the practice standards described in part 1 of this video. Students typically start out learning narrative charting. The main difference between focus charting and narrative charting is the amount of information that is charted. In focus charting only significant events are charted. This type of charting is typically supported by another method of documentation that captures regular occurrences such as a tick sheet or graphic sheet. The type you will use will depend on your work setting. In many settings the DEAR format is used for focus charting. These notes are an important part of the health care record. Be sure that the patient's name and the date appear on each page of the notes. You will also need to identify your discipline at the bottom of the form. The purpose of documentation is communication to support quality and continuity of care so make sure it is legible. If it isn't, serious errors in care can occur. Nursing notes are arranged by columns. For every entry, record the time of documentation in the Time charted column. Late entries are acceptable. In the Time of care column Record the time that the care occurred. Document your work in chronological order. In the Focus column Enter the appropriate client-centered focus word or words. Keep it short and consistent with the focuses used by others. Typically there is a list of focuses specific to each client within the care plan. In the DEAR column Record the appropriate DEAR mnemonic in logical order each time a new type of data is recorded or a new focus is used. Note that the acronym DEAR does not need to be used in order nor does each letter in the acronym need to be used with each entry. You will need to use logic and clinical discretion to decide what is appropriate for each situation. In the Notes column Write the DEAR corresponding information within the notes clearly and legibly. At the conclusion of your entry, or wherever there is blank space at the end of a line, draw a line from the last word to the end of the row to eliminate the possibility of others adding data in unused space. Sign with your name and designation at the end of each entry and/or page of documentation. Write clearly and do not try to squish information on the page at the expense of legibility. D stands for Data. Both subjective and objective that support the identified focus are noted. This data describes patient perceptions and clinical observations at the time of a significant event. Ask yourself what the client said that supports your focus. What did you hear, see, feel or smell during your assessment that supports your actions. Don't just document strings of data absent a connection to an identified focus. Data should link to purposeful therapeutic contact. Documenting only strings of data becomes meaningless. Routines can be captured in a better way, like on a graphic sheet. Remember, in focus charting you focus on meaningful events that are relevant to the client's care plan. E stands for Evaluation. This part of focus charting is the recorders interpretation or synthesis of the situation. Sometimes it will develop into another focus. When the data is obvious this evaluation statement in the chart is often skipped. Use it when you need to clarify your evaluation of the data. A stands for Action. Each member of the health care team should document their own actions so remember not to document for someone else. Any interventions should be documented under the appropriate focus. Remember care not documented is care that was not done so write down your interventions under the appropriate focus. This documentation is critical! R stands for Response. Document outcomes from your interventions or observed progress towards goals. When documenting follow the procedures in your setting. Typically you will need to complete a Provider Identification Record at the front of the chart. In hard copy records use only ball point pen with black ink. Do not use gel ink because it smudges. To correct an error: Simply draw a single line through the mistake, write "error," then initial. Be sure to check the policy where you work for other requirements. Thank you for watching. Please let me know what else you would like to see. For more information about the importance of documentation please see part 1 of this video. I also recommend taking the practice quiz identified in part 1, which is available through the College of Nurses of Ontario.

• published: 09 Apr 2013
• views: 8433