Nurse's Pocket Guide

Example 2. SAMPLE OF FOCUS CHARTING ®
FOR PROTOTYPE PLAN OF CARE
D Data A Action R Response
DATE TIME FOCUS ®
6/29/07 1900 Skin integrity D: Scant amount serous
drainage on dressing,
wound borders pink, no
odor present, denies
discomfort except with
direct palpation of
surrounding tissue.
A: NS irrig. as ordered.
Sterile wet dressing
applied with paper tape.
R: Wound clean—no
drainage present.
Signed:E.Moore,RN
6/29/07 2100 Pain L foot D: Reports dull/throbbing
ache L foot 4/10—no
radiation. Muscles tense,
restless in bed.
A: Foot cradle on bed.
Darvocet-N 100 mg
given PO.
Signed: M. Siskin, RN
2200 Pain L foot R: Reports pain relieved
0/10. Appears relaxed.
Signed: M. Siskin, RN
6/30/07 1100 Learning Need, D: Attended group teaching
Diabetic session with wife. Both
Teaching have read “Understanding
Your Diabetes.”
A: Reviewed list of
questions/concerns from
R.S. and wife. (Copy
attached to teaching
plan.) R.S. demonstrated
insulin administration
technique for wife to
observe.
Procedure handout
sheet for future reference
provided to couple.
Meeting scheduled with
dietitian for 1300 today
to discuss remaining
questions.
68 NURSE’S POCKET GUIDE
(Continued)