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Fdar

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Deannah Tampus

The document describes Focus-Data-Action-Response (F-DAR) charting, which organizes health information in a patient's record with three columns: Date/Hour, Focus, and Progress Notes. The Progress Notes column contains three sections - Data (assessment findings), Action (nursing care provided), and Response (patient outcomes). Several examples of completed F-DAR charts are provided addressing issues like pain, fever, risk of infection, nausea, and more. F-DAR charting aims to make the patient and their concerns the focus of care through systematic documentation of assessments, interventions, and responses.

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FDAR
Definition Focus Charting of F-DAR is intended to make the client and client concerns and strengths the focus of care. It is a method of organizing health information in an individuals record. Focus Charting is a systematic
Focus Charting Parts Three columns are usually used in Focus Charting for documentation: Date and Hour Focus Progress Notes The progress notes are organized into (D) data, (A) action, and (R) response, referred to as DAR (third column).
Date/Hour Focus Progress Notes 3/7/2010 8:00pm Focus of care, this may be: a nursing diagnosis a sign or a symptom an acute change in the condition behavior Data Action Response
Progress Notes Data (D) The data category is like the assessment phase of the nursing process. It is in this category that you would be writing your assessment cues like: vital signs, behaviors, and other observations noticed from the patient. Both subjective and objective data are recorded in the data category.
Progress Notes Action (A) The action category reflects the planning and implementation phase of the nursing process and includes immediate and future nursing actions. It may also include any changes to the plan of care.
Progress Notes Response (R) The response category reflects the evaluation phase of the nursing process and describes the clients response to any nursing and medical care.
Date/Hou r Focus Progress Notes 5/20/201 08:00am 10:00am Pain D: Reports of sharp pain on the abdominal incision area with a pain scale of 8 out of 10. +Facial grimacing and guarding behavior. The patient is restless and irritable A: Administered Celecoxib 200mg IV. Encouraged deep breathing exercises and relaxation techniques R: Patient reports pain was relieved Signature Name F-DAR for Pain
Date/Hou r Focus Progress Notes 5/20/201 0 8:00pm 10:00pm Hyperthermia D: Temperature of 38.9 OC via axilla. Skin is flushed and warm to touch A: Tepid Sponge Bath (TSB) done. Administered 500mg IV Paracetamol prn for fever as per doctors order. Encouraged adequate oral fluid intake. Encouraged adequate rest. R: Temperature decreased from 38.9 to 37.1 OC Signature Name F-DAR for Hyperthermia
Date/Hour Focus Progress Notes 5/21/201 5 8:00am 3:00pm Risk for infection D: With incision site in front of left ear extending down and around the ear and into neck approximately 6 inches in length, without dressing, Jackson-Pratt drain in left neck below ear secured in place with suture. A: Assessed sites for signs of infection, emptied Jackson Prat drain and maintained on negative pressure, instructed patient not to touch the incision sites, taught signs and symptoms of infection. R: No swelling or bleeding; bluish discoloration left ear noted. JP drained 20 mL bloody drainage, patient states understanding of teaching given. Signature Name F-DAR for Risk for infection
Date/Hou r Focus Progress Notes 4/20/202 1 8:00am 6:00pm Edema D: Swelling of upper extremities noted, non- pitting, latest albumin level of 1.98 g/dl dated August 3, 2015 A: Monitored intake and output strictly, intravenous fluid regulated at 40cc/hr; followed- up requested 50 cc Human Albumin 20%, monitored for signs and symptoms of pulmonary congestion and progression of edema, added Prosure and egg whites to feeding as ordered. R: Still with swelling of upper extremities noted, clear breath sounds noted upon auscultation, with no signs of pulmonary congestion. Signature Name F-DAR for Edema
Date/Hour Focus Progress Notes 4/10/2021 8:00pm 6:00am Nausea D: I feel like my stomach is filling up with pressure again and Im nauseated, abdomen round and soft, gastrostomy bag at body level, rare bowel sounds noted. A: Keep gastrostomy bag lower than body level, abdominal status monitored closely, documented time, amount of drainage and discomfort, instructed to report for recurrence of nausea and abdominal discomfort. R: I feel better now, approximately 200 cc of golden watery feces removed and flatus noted. Signature Name F-DAR for Nausea
Date/Hou r Focus Progress Notes 1/2/2021 8:00am 6:00pm Chest Pain D: Gasakit ang dughan ko with complaints chest pain graded as 8 in a scale of 10, radiating to jaw and relieved by rest as claimed, with BP of 90/60 mmHg, cardiac rate of 106 beats/min, synchronous with pulse rate. A: Instructed to maintain on complete bed rest, Dr. Ruiz, MROD, informed, Isordil 5 mg SL given, started oxygen at 2 liters /min via nasal cannula, stat ECG taken, Troponin I taken, attached to cardiac monitor, instructed to report progression of chest pain. R: Severity of pain decreased to 5/10 as claimed, resting comfortably in bed, ECG revealed ST elevation MI, with troponin result of 3. Signature Name F-DAR for Chest Pain
Date/Hou r Focus Progress Notes 1/6/202 1 9:00am 9:30am Decreased level of consciousness Unresponsivene ss D: GCS 3, no eye opening, no verbal output, and no motor response, anisocoric pupils, with temperature of 39oC A: Monitored neurologic status and vital signs closely, Dr. Cruz, MROD was notified, head of the bed at 30 degrees elevation, body maintained on neutral position, continuous ice bath performed, due dose of Mannitol 175 cc IV bolus given, will closely monitor for further deterioration of neurologic status. D: Pulse and BP unappreciated, no spontaneous breathing with oxygen saturation of 89%; fixed dilated pupils of 8mm; ventricular fibrillation noted on the monitor. A: High quality CPR done, Dr. Cruz, MROD seen and examined the patient, significant others were appraised of patients condition; ventilation via bag mask at 10 liters/mi given, defibrillation at 36 joules done by Dr. Cruz, MROD, Epinephrine 1 mg given with 3 minutes interval for 3 doses, flushed with 20 cc normal saline and arm raised thereafter, monitored for return of spontaneous
Date/Hou r Focus Progress Notes 9:45am Asystole -continuation- D: Flat line tracing on the monitor, pulse unappreciated, patients family opted to stop resuscitative measures A: Waiver for DNR and refusal for emergency medications secured and signed by patients wife, rhythm strip taken, pronounced clinically dead by Dr. Cruz, MROD, post mortem care done; brought to morgue via canvass by Mr. Jose Fernandez (Orderly on duty) Signature Name
Avoid phrases like: Monitored for any untoward signs and symptoms Referred accordingly Made comfortable in bed Due meds given Provided calm and restful environment
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Fdar

  • 2. Definition Focus Charting of F-DAR is intended to make the client and client concerns and strengths the focus of care. It is a method of organizing health information in an individuals record. Focus Charting is a systematic
  • 3. Focus Charting Parts Three columns are usually used in Focus Charting for documentation: Date and Hour Focus Progress Notes The progress notes are organized into (D) data, (A) action, and (R) response, referred to as DAR (third column).
  • 4. Date/Hour Focus Progress Notes 3/7/2010 8:00pm Focus of care, this may be: a nursing diagnosis a sign or a symptom an acute change in the condition behavior Data Action Response
  • 5. Progress Notes Data (D) The data category is like the assessment phase of the nursing process. It is in this category that you would be writing your assessment cues like: vital signs, behaviors, and other observations noticed from the patient. Both subjective and objective data are recorded in the data category.
  • 6. Progress Notes Action (A) The action category reflects the planning and implementation phase of the nursing process and includes immediate and future nursing actions. It may also include any changes to the plan of care.
  • 7. Progress Notes Response (R) The response category reflects the evaluation phase of the nursing process and describes the clients response to any nursing and medical care.
  • 8. Date/Hou r Focus Progress Notes 5/20/201 08:00am 10:00am Pain D: Reports of sharp pain on the abdominal incision area with a pain scale of 8 out of 10. +Facial grimacing and guarding behavior. The patient is restless and irritable A: Administered Celecoxib 200mg IV. Encouraged deep breathing exercises and relaxation techniques R: Patient reports pain was relieved Signature Name F-DAR for Pain
  • 9. Date/Hou r Focus Progress Notes 5/20/201 0 8:00pm 10:00pm Hyperthermia D: Temperature of 38.9 OC via axilla. Skin is flushed and warm to touch A: Tepid Sponge Bath (TSB) done. Administered 500mg IV Paracetamol prn for fever as per doctors order. Encouraged adequate oral fluid intake. Encouraged adequate rest. R: Temperature decreased from 38.9 to 37.1 OC Signature Name F-DAR for Hyperthermia
  • 10. Date/Hour Focus Progress Notes 5/21/201 5 8:00am 3:00pm Risk for infection D: With incision site in front of left ear extending down and around the ear and into neck approximately 6 inches in length, without dressing, Jackson-Pratt drain in left neck below ear secured in place with suture. A: Assessed sites for signs of infection, emptied Jackson Prat drain and maintained on negative pressure, instructed patient not to touch the incision sites, taught signs and symptoms of infection. R: No swelling or bleeding; bluish discoloration left ear noted. JP drained 20 mL bloody drainage, patient states understanding of teaching given. Signature Name F-DAR for Risk for infection
  • 11. Date/Hou r Focus Progress Notes 4/20/202 1 8:00am 6:00pm Edema D: Swelling of upper extremities noted, non- pitting, latest albumin level of 1.98 g/dl dated August 3, 2015 A: Monitored intake and output strictly, intravenous fluid regulated at 40cc/hr; followed- up requested 50 cc Human Albumin 20%, monitored for signs and symptoms of pulmonary congestion and progression of edema, added Prosure and egg whites to feeding as ordered. R: Still with swelling of upper extremities noted, clear breath sounds noted upon auscultation, with no signs of pulmonary congestion. Signature Name F-DAR for Edema
  • 12. Date/Hour Focus Progress Notes 4/10/2021 8:00pm 6:00am Nausea D: I feel like my stomach is filling up with pressure again and Im nauseated, abdomen round and soft, gastrostomy bag at body level, rare bowel sounds noted. A: Keep gastrostomy bag lower than body level, abdominal status monitored closely, documented time, amount of drainage and discomfort, instructed to report for recurrence of nausea and abdominal discomfort. R: I feel better now, approximately 200 cc of golden watery feces removed and flatus noted. Signature Name F-DAR for Nausea
  • 13. Date/Hou r Focus Progress Notes 1/2/2021 8:00am 6:00pm Chest Pain D: Gasakit ang dughan ko with complaints chest pain graded as 8 in a scale of 10, radiating to jaw and relieved by rest as claimed, with BP of 90/60 mmHg, cardiac rate of 106 beats/min, synchronous with pulse rate. A: Instructed to maintain on complete bed rest, Dr. Ruiz, MROD, informed, Isordil 5 mg SL given, started oxygen at 2 liters /min via nasal cannula, stat ECG taken, Troponin I taken, attached to cardiac monitor, instructed to report progression of chest pain. R: Severity of pain decreased to 5/10 as claimed, resting comfortably in bed, ECG revealed ST elevation MI, with troponin result of 3. Signature Name F-DAR for Chest Pain
  • 14. Date/Hou r Focus Progress Notes 1/6/202 1 9:00am 9:30am Decreased level of consciousness Unresponsivene ss D: GCS 3, no eye opening, no verbal output, and no motor response, anisocoric pupils, with temperature of 39oC A: Monitored neurologic status and vital signs closely, Dr. Cruz, MROD was notified, head of the bed at 30 degrees elevation, body maintained on neutral position, continuous ice bath performed, due dose of Mannitol 175 cc IV bolus given, will closely monitor for further deterioration of neurologic status. D: Pulse and BP unappreciated, no spontaneous breathing with oxygen saturation of 89%; fixed dilated pupils of 8mm; ventricular fibrillation noted on the monitor. A: High quality CPR done, Dr. Cruz, MROD seen and examined the patient, significant others were appraised of patients condition; ventilation via bag mask at 10 liters/mi given, defibrillation at 36 joules done by Dr. Cruz, MROD, Epinephrine 1 mg given with 3 minutes interval for 3 doses, flushed with 20 cc normal saline and arm raised thereafter, monitored for return of spontaneous
  • 15. Date/Hou r Focus Progress Notes 9:45am Asystole -continuation- D: Flat line tracing on the monitor, pulse unappreciated, patients family opted to stop resuscitative measures A: Waiver for DNR and refusal for emergency medications secured and signed by patients wife, rhythm strip taken, pronounced clinically dead by Dr. Cruz, MROD, post mortem care done; brought to morgue via canvass by Mr. Jose Fernandez (Orderly on duty) Signature Name
  • 16. Avoid phrases like: Monitored for any untoward signs and symptoms Referred accordingly Made comfortable in bed Due meds given Provided calm and restful environment