- 1). Write the date and time. Make a subjective or objective statement identifying the concern or condition you found in your assessment. The focus could be a change in the patient's condition, an event such as surgery or hospital discharge or a change in skin integrity, or a treatment. Focus charting can be in the form of a statement or a nursing diagnosis. An example nursing diagnosis would be alteration in comfort related to post-op pain or the problem could be listed as a statement such as Post- op pain. Another example could be knowledge deficit related to discharge care or as a statement such as discharge planning.
- 2). State the action or actions that were taken or need to be taken to address the problem you identified in your assessment. Be specific and include date and time. This may include calling the doctor, initiating antibiotic therapy or pain medication, restarting intravenous fluids, or patient education. An example of the action for a focus of alteration in comfort related to pain might be: assessing pain every two hours, administering pain medication every four hours as needed and repositioning the patient every hour.
- 3). Chart the patient's response to the problem and be specific. This is your evaluation of the patient's response to the action that was implemented. Document the date and time and objective and subjective responses to the action that was taken. In the example of the patient in pain, assess the patient's response after you administered the actions you listed in the action step. For example, assess if the patients pain level has decreased after receiving pain medication and being repositioned. Ask the patient to rate their pain before and after taking the medication. Document their response to your action including date and time.
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