FDAR Focus Data Action Response

FOCUS CHARTING - describes the patient's perspective and focuses on

documenting the patient's current status, progress towards goals, and
response to interventions.

Purpose of Fdar charting

To easily identify critical patient issues/concerns in the Progress

Notes.

To facilitate communication among all disciplines.

To improve time efficiency with documentation.

To provide concise entries that would not duplicate patient

information already provided on flow sheet/checklist.
When is Fdar necessary

To describe a patient problem/ focus/ concern from the

care 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 the
topic of the note
To describe all specifics regarding patient/family teaching

-To document a significant event or unusual episode in patient care

Example: Admission
Pre- (specify procedure) assessment
Post- (specify procedure) assessment
Pre-transfer assessment
Discharge Planning
Discharge Status
Transfusion RBC
Begin thrombolytic therapy
PRN medication required
-To identify an exemption to the expected outcome
Example: Wheezes left base
Nausea
-To document an activity or treatment was not carried out
-To best describe patients condition in relation to medical diagnosis

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 patients concern and/or plan of care e.g. health
teaching per shift. Hence, GENERAL NOTES ARE NOT ALLOWED!
Document patients status on admission, for every transfer to
/from another unit, or discharge.
Follow the Dos of documentation
Use BLUE or BLACK ink of pen for AM and PM shift, RED ink for
NIGHT shift.

Fdar charting
Focus identifies the content or purpose of the
narrative entry and is separated from the
body of the notes in order to promote easy
data retrieval and communication.
Data

- statements contain objective and/or

subjective information.

Action statements that contain nursing

interventions (basic, perspective,
independent) past, present or future.
- it also contains collaborative orders
Response Evident patient outcomes or
response
INFORMATION 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 ensure
complete documentation.
DATA and ACTION are recorded at one hour, and
RESPONSE is not added until later, when the patient outcome is evident.

DOCUMENTATION DOS AND DONTS

DO
-

DO time and date all entries.

DO use flowsheet/ checklist. Keep information on
flowsheet/checklist current. DO chart as you make observations.
DO write your own observations and sign your own name. Sign
and initial every entry.
DO describe patient's behavior and use direct patient quotes
when appropriate.
DO record exactly what happens to patient and care given. DO
be factual and complete.
DO draw a single line thru an error. Mark this entry as error and
sign your name.
DO use only approved abbreviations
DO use next available line to chart.
DO document patient's current status and response to
medical care and treatments.
DO write legibly. DO use ink. DO use accepted chart
forms.

DONTS
DON'T begin charting until you check the name and identifying
number 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 data
already charted on the flowsheet/checklist.
DON'T make or sign an entry for someone else. DON'T change
and 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 or
omission.
DON'T white out or erase an error. DON'T throw away notes
with an error on them.
DON'T squeeze in a missed entry or leave space for someone
else 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 taskoriented.
Indicate the date and time of entry in the first column.

RESPONSE is used alone to indicate a care of plan goal has been

accomplished

ACTION and RESPONSE are repeated without additional data to show the
sequence of decision making based on evaluating patient response to the
initial intervention.

STAT & PRN MEDICATION

DATA is used alone when the purpose of the note is to document

assessment finding and there is no flowsheet /checklist for that purpose
NOTIFICATION OF PHYCISIAN

Begin the note with ACTION when the patient's interaction begins with
intervention or when including data would be unnecessary repetition.

Workshop No.1
Patient having severe midsternal chest pain, radiating down left arm. Sinus
tachycardia on monitor with occasional PVC noted.Morphine SO4 4mg IV
given.Restless. BP160/90
mmHG. Teary eyed and saying Sakit na gyud
kaayo ang akong dughan. Valium 5mg po given.
Output no.1

ADMISSION

Workshop No. 2
At 6pm, when the nurse entered the room she found the patient on the
floor between the bed and IV stand. When the patient saw the nurse, she
stated Tabangi ko mam, nahulog ko. Active bleeding from nose and some
blood in mouth. Tranexamic Acid 500 mg given.
Output 2
REASSESSMENT

DISCHARGE
Workshop No. 3

At 8:30 am, the nurse noted the patient was gasping for air, not responding
to verbal stimuli. Rales heard in all lung fields. A stat dose of Lasix 40mg IV
was ordered. After 30 minutes respiratory distress and diaphoresis were
noted. Skin remained pale. No change in LOC.
Output 3