Nurse's Pocket Guide

Example 2. SAMPLE OF FOCUS CHARTING ®
FOR PROTOTYPE PLAN OF CARE (Continued)
D Data A Action R Response
DATE TIME FOCUS ®
R: R.S. more confident in
demonstration, performed
activity correctly
without hesitation or
hand tremors. He
explained steps of procedure
and reasons for
actions to wife. Couple
identified resources to
contact if questions/
problems arise.
The following is an example of documentation of a client need/concern
that currently does not require identification as a client problem
(nursing diagnosis) or inclusion in the plan of care and therefore is
not easily documented in the SOAP format:
6/28/07 2120 Gastric distress D: Awakened from light
sleep by “indigestion/
burning sensation.”
Places hand over
epigastrie area. Skin
warm/dry, color pink,
vital signs unchanged.
A: Given Mylanta 30 mL
PO. Head of bed elevated
approximately 15
degrees.
R: Reports pain relieved.
Appears relaxed, resting
quietly.
Signed:E.Moore,RN
FOCUS Charting®, Susan Lampe, RN, MS: Creative Nursing
Management, Inc., 614 East Grant Street, Minneapolis, MN 55404.
PUTTING THEORY INTO PRACTICE 69