Focus Charting in Pediatric Ward: Medsurgical Clinical
Focus Charting in Pediatric Ward: Medsurgical Clinical
Focus Charting in Pediatric Ward: Medsurgical Clinical
Response
● What happened to the patient as a result of the
action/intervention?
● What are the patient outcomes?
● Does the current status or behavior match the desired
9 USES OF THE FOCUS COLUMN
outcome?
1. When the purpose of the note is to evaluate progress toward
the defined patient outcome from the plan of care, USE: the
patient problem/focus/concern from the care plan - use of
same word provides visual link throughout the stages of the
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[NCM 112 CLINICAL] FOCUS CHARTING ON PEDIA – Pro. Orense
Narrative charting
● Traditional method of nursing documentation
● Chronological account written in paragraphs describing
client’s status, interventions, treatments, and the client’s
response to treatments
● Most flexible
4 Critical Components:
1. Database (assessment data)
2. Problem List (client’s problems numbered according to
when identified)
3. Initial Plan (outline of goals, expected outcomes, learning
needs, and further data, if needed)
4. Progress notes (charting based on the SOAP, SOAPIE, or
SOAPIER format)