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FDAR - Nurses Notes

FDAR - Nurses Notes

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Published by Carmzy Eyla

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Published by: Carmzy Eyla on Feb 09, 2011
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10/08/2013

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FDAR – Focus Data Action ResponseFOCUS CHARTING
- describes the patient's perspective and focuses ondocumenting the patient's current status, progress towards goals, andresponse to interventions.Purpose of Fdar charting
 To easily identify critical patient issues/concerns in the ProgressNotes.
 To facilitate communication among all disciplines.
 To improve time efficiency with documentation.
 To provide concise entries that would not duplicate patientinformation already provided on flow sheet/checklist.When is Fdar necessary
To describe a patient problem/ focus/ concern from thecare plan
To document an activity or treatment that was carried out
To document a new findings
 
To document an acute change in patient's condition
 
To identify the discipline making the entry as well as thetopic of the note
To describe all specifics regarding patient/family teaching
-To document a significant event or unusual episode in patient careExample: AdmissionPre- (specify procedure) assessmentPost- (specify procedure) assessmentPre-transfer assessmentDischarge PlanningDischarge StatusTransfusion RBCBegin thrombolytic therapyPRN medication required-To identify an exemption to the expected outcomeExample: Wheezes left baseNausea-To document an activity or treatment was not carried out-To best describe patient’s condition in relation to medical diagnosis 
DOCUMENTATION DO’S AND DONT’SDO
-DO time and date all entries.-DO use flowsheet/ checklist. Keep information onflowsheet/checklist current. DO chart as you make observations.-DO write your own observations and sign your own name. Signand initial every entry.-DO describe patient's behavior and use direct patient quoteswhen appropriate.-DO record exactly what happens to patient and care given. DObe factual and complete.-DO draw a single line thru an error. Mark this entry as “error andsign your name.”-DO use only approved abbreviations-DO use next available line to chart.-
DO document patient's current status and response tomedical care and treatments.
-
DO write legibly. DO use ink. DO use accepted chartforms.DONT’S
-DON'T begin charting until you check the name and identifyingnumber on the patient's chart on each page.-DON'T chart procedures or cares in advance.-DON'T clutter notes with repititive or frequently changing dataalready charted on the flowsheet/checklist.
-
DON'T make or sign an entry for someone else. DON'T changeand entry because someone tells you.-DON'T label a patient or show bias.-DON'T try to cover up a mistake or incident by inaccuracy oromission.-DON'T “white out” or erase an error. DON'T throw away noteswith an error on them.-DON'T squeeze in a missed entry or “leave space” for someoneelse who forgot to chart. DON'T write in the margin.-DON'T use meaningless words and phrases, such as “good day”or “no complaints”-
DON'T use notebook paper or pencil.GENERAL GUIDELINES
-Focus charting must be evident at least once every shift.-Focus charting must be patient-oriented not nursing task-oriented.-Indicate the date and time of entry in the first column.-Separate the topic words for the body of notes:a. Focus note written on the second column.b. Data, Action and Response on the third column.
-
Sign name ( e.g. Geraldine M. Amiscaray, RN or G. Amiscaray,RN) for every time entry-Document only patient’s concern and/or plan of care e.g. healthteaching per shift. Hence, GENERAL NOTES ARE NOT ALLOWED!-Document patient’s status on admission, for every transfer to/from another unit, or discharge.-Follow the Do’s of documentation-Use BLUE or BLACK ink of pen for AM and PM shift, RED ink forNIGHT shift.Fdar charting
Focus
– identifies the content or purpose of thenarrative entry and is
separated
from thebody of the notes in order to
promote easydata retrieval and communication
.
Data
- statements contain
objective
and/or
subjective
information.
Action
– statements that contain nursinginterventions (basic, perspective,independent) past, present or future.- it also contains collaborative orders
Response
– Evident patient outcomes orresponseINFORMATION FROM ALL THREE CATEGORIES (DATA,ACTION,RESPONSE)should be used only as they are RELEVANT or AVAILABLE.However, all appropriate information should be included to ensurecomplete documentation.
DATA
and
ACTION
are recorded at one hour, and
RESPONSE
is not added until later, when the patient outcome is evident.
RESPONSE
is used alone to indicate a care of plan goal has beenaccomplished
ACTION
and
RESPONSE
are repeated without additional data to show thesequence of decision making based on evaluating patient response to theinitial intervention.
 
DATA
is used alone when the purpose of the note is to documentassessment finding and there is no flowsheet /checklist for that purposeBegin the note with
ACTION
when the patient's interaction begins withintervention or when including data would be unnecessary repetition.
ADMISSIONREASSESSMENTDISCHARGESTAT & PRN MEDICATIONNOTIFICATION OF PHYCISIAN
Workshop No.1
Patient having severe midsternal chest pain, radiating down left arm. Sinustachycardia on monitor with occasional PVC noted.Morphine SO4 4mg IVgiven.Restless. BP160/90 mmHG. Teary eyed and saying “Sakit na gyudkaayo ang akong dughan”. Valium 5mg po given.Output no.1
Workshop No. 2
At 6pm, when the nurse entered the room she found the patient on thefloor between the bed and IV stand. When the patient saw the nurse, shestated “Tabangi ko mam, nahulog ko.” Active bleeding from nose and someblood in mouth. Tranexamic Acid 500 mg given.Output 2
Workshop No. 3

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