OBJECTIVE:

To be able to understand the FDAR system

of documentation

To be able to write focus format progress

notes applicable to your health care
profession and practice setting.

NURSING DOCUMENTATION

Documentation is any written or

electronically generated information about
a client that describes the care or service
provided to that client

NURSING DOCUMENTATION
Written evidence of:

The interactions between and among health care

professionals, clients, their families, and health care
organizations.

The administration of test, procedures, treatments, and

clients education.

The results of, or clients response to, diagnostic tests and

intervention

PURPOSE OF
DOCUMENTATION
A.

TO FACILITATE COMMUNICATION

Nurses communicate to other nurses and care providers

their assessments about status of clients, nursing
interventions that are carried out and the results of these
interventions.

Thorough, accurate documentation decreases the

potential for miscommunication and errors

PURPOSE OF
DOCUMENTATION
B.

TO PROMOTE GOOD NURSING CARE

Encourage nurses to assess client progress and determine

which intervention are effective and which are
ineffective, and identify and document changes to the
plan of care as needed.

Facilitating nursing research, all of which have the potential

to improve the quality of nursing practice and client care.

PURPOSE OF
DOCUMENTATION
C.

TO MEET PROFESSIONAL & LEGAL

STANDARDS

Documentation is a valuable method for demonstrating

that, within the nurse-client relationship, the nurse has
applied nursing knowledge, skills and judgment
according to professional standards.

The nurses documentation may be used as evidence in

legal proceedings such as lawsuits, coroners inquests,
and disciplinary hearings through professional regulatory
bodies.

FOCUS CHARTING

Focus Charting describes the patients perspective and

focuses on documenting the patients current status,
progress towards goals and response to interventions.

With this system of documentation, the nurse identifies a

focus based on client concerns or behaviors determined
during the assessment.

ADVANTAGES OF FOCUS
CHARTING
Format
Useful

is easy to learn.

way to organize patient progress notes.

Provides

easy, quick information retrieval.

Facilitates

documentation of all information needed to meet professional

and accreditation standards.

Supports

multidisciplinary clinical collaborative practice by focusing on the

patient and promoting communication.

Supports

professional critical thinking.

Decreases
Decreases

duplication of information on the health record.

time spent in charting especially if used in conjunction with a

well designed, comprehensive flow sheet.

Elements of FOCUS
CHARTING
F

FOCUS

DATA

ACTION

RESPONSE

Problem identified from the patient. 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 .
Is the subjective and/or objective information
supporting the stated focus or describing the
observations at the time of a significant event
Immediate or future nursing actions based on the
nurses assessment/evaluation of the clients
condition.
Describes the patient outcome/response to
interventions or describes how
goals have been attained.

How to develop the focus

REFERS TO

EXAMPLE

A sign or symptom

Hypotension, or Chest Pain

A patient behavior

Inability to ambulate

An acute change in the patient

condition

Respiratory distress, code blue,

diabetic coma

A significant event in the

patients therapy

Surgery ( Appendectomy),
Transfusion of packed RBC

A special need

Discharge Planning Need, Family

conference

medical diagnosis

PVCs (or other cardiac

arrhythmias), hyperbilirubinemia Competent R.N.s in ICU

Guidelines for writing focus

list

Enter a focus note only when it is required.

Do not write a focus note because its time (end of shift),
or because you want to indicate that you observed the
patient at regular intervals.
Remember, the goal is to communicate essential patient
information.
To assist you in choosing a focus, ask yourself What is the
focus of my care or concern for this patient? Is this the main
topic of the note? Is it patient related and not treatment
related? Is it specific? (e.g., right ankle edema instead of
edema)

Sample of focus list

no

FOCUS

1.

Ineffective airway
clearance

2.

Anxiety re: financial concern

3.

Inadequate Intake of food

4.

Spiritual Distress

ACTIVE

7/20/2013

RESOLVED

7/22/2013

REINSTATE
D

DISCIPLINE

Nursing / RT

7/22/2013

Social Worker

7/22/2013

Dietetian

7/22/2013

7/23/2013

Pastoral Care

Identify the Focus for the

Chart Entry
Date/Time

FOCUS

acute
grieving,
emotional
status

PROGRESS NOTE

DATA: Staring out window, refused to

eat lunch, states Just leave me
alone.--------------------------ACTION: Patient and wife informed of
Cancer Support Group available in
hospital. Arrangements made with
chaplain to speak to patient this
afternoon.--------------K. Miller, SW

Identify the Focus for the

Chart Entry
Date/Time

FOCUS

Constipation,
bowel
elimination

PROGRESS NOTE

DATA: states bowel movements are

hard and difficult to pass. Has had no
BM for 3 days. -------------------ACTION: encouraged to drink plenty
of fluids, eat more fruits and
vegetables and exercise
more.----------------RESPONSE: states will try above
measures and let staff know if has
any results on next visit. -----S. Smith
RN

Data-Action-Response

Charting in these categories completes

the clinical decision-making cycle,
organizes the focus note, promotes critical
thinking and assists the writer to
communicate to other health professionals
in a logical and concise manner.

1.

General Guidelines for

Charting in the Progress
Notes

The words DATA or (D), ACTION or (A), RESPONSE or (R) are included in the
documentation of the progress notes to remind the writer of complete
documentation for each focus.

2.

The words DATA, ACTION, and RESPONSE (or D, A, R, ) are written along the
left margin of the Patient Progress Notes in order that the information in each
category may be more easily located.

3.

The full signature of the health care professional making the entry should
appear only at the end of the complete entry for the time entered in the
Date/Time column. This includes first initial, last name and professional
designation. e.g., A. J. Dela Cruz R.N.
Note: If a name stamp is used in a facilities standard patient chart, then
this should be used with signature above.

4.

General Guidelines for

Charting in the Progress
Notes

DATA and ACTION recorded at one time, RESPONSE is not added

until later, when patient outcome is evident.

Date /Time

1/31/2013
10:45 am

11:45am

FOCUS

1. rt. elbow
pain

NURSESS PROGRESS NOTE

F#1
DATA: Complains of stabbing right elbow
(operative) pain 7 on scale of 10.
ACTION: Demerol 50 mg. I.M., given in left
Ventero gluteal muscle.
RESPONSE: Resting in bed. States pain
has
decreased to a level of 3 out of 10.-----------------------------C. Adams, RN

5.

6.

General Guidelines for

Charting in the Progress
Notes

It may not be necessary to use all four categories (DATA,

ACTION, RESPONSE) with each FOCUS entry. These
categories are guides to organize the documentation, and
should be used only as relevant or reasonable. Any
combination of the categories can be used (only one,
two, three or all four) in the order that best
communicates to other health care team members.
RESPONSE is used alone to indicate a care plan goal has
been accomplished.

General Guidelines for

Charting in the Progress
Notes

EXAMPLE:
Date /Time

1/31/2013
10:45 am

FOCUS

1. patient
teaching
dressing
change

NURSESS PROGRESS NOTE

F#1
RESPONSE: Demonstrated independent
change of his abdominal dressing
correctly
using aseptic technique. -----W.Green, RN

6.

General Guidelines for

Charting in the Progress
Notes
DATA or DATA & Response is used alone when the purpose of a note
is to document assessment findings.

EXAMPLE #1
Date /Time

7/12/13
2:00 pm

FOCUS

Return from
P.A.C.U

NURSESS PROGRESS NOTE

DATA: Received via stretcher, awake and
alert, vital signs stable (see graphic record). IV
right forearm patent (see fluid balance record).
Foley catheter intact draining clear yellow
urine, dressing RLQ dry and intact, moving all
extremities voluntarily, states she has minimal
pain 3 out of 10. -----------------Y. See, RN

General Guidelines for

Charting in the Progress
Notes

EXAMPLE #2:
Date /Time

1/31/2013
10:45 am

FOCUS

Admission
Assessment

NURSESS PROGRESS NOTE

D- Receive from ER via
stretcher,conscious, coherent, with IV of
4PLR 1L + 8.25 meq KCl @ 66 ugtts/min
infusing well @ the R
forearm
on O2 vial nasal cannula @ 3 lmp.
V/S BP- 110/70mmHG, RR-26 cpm, PR- 90
bpm, T-36.9 celsius/axilla.

A- Transfer to room & orient to room set

up------------------S/N A.J. Dela Cruz

7.

General Guidelines for

Charting in the Progress
Notes

Action and Response are repeated without additional data to

show the sequence of decision making based on evaluating
patient response to the initial intervention.

Date /Time

7/12/13
8:00 Am

1:00PM

FOCUS

Nausea

NURSESS PROGRESS NOTE

F#1
D- I feel like my stomach is feeling up with pressure
again and Im nauseated
Abdomen round and soft
Gastronomy bag at body level. Rare bowel sounds
A- gastronomy bag lowered
R- I feel like better now
Approximately 200cc golden fluid returned as much
flatus________________________S/N A.J.Dela Cruz
A- Keep gastronomy bag at body level
Monitor abdominal status
Monitor how long bag is tolerated at body level
Document any discomfort
Patient instructed to call nurse when he is uncomfortable
R- I understand Plan
------------------------------S/N A.J. Dela Cruz

8.

General Guidelines for

Charting in the Progress
Notes
Begin the note with ACTION when the patient interaction
begins with intervention or when including date would be
unnecessary repetition

Date /Time

7/12/13
10:00 am

FOCUS

Health
Teaching
Digoxin

NURSESS PROGRESS NOTE

A- Patient instructed on the action and
side effect of digoxin.
Given digoxin information card
Discusses when he would call the
physician about the medicine
R- return demonstration of radial pulse
I understand the purpose of medication
---------------------S/N A.J. Dela Cruz

9.

General Guidelines for

Charting in the Progress
In case with multipleNotes
problem in 1 shift

Date /Time

7/12/13

FOCUS
1. Ineffective
Breathing Pattern

F#1
D- increase respiratory rate of 24cpm
Use of accessory muscle to breath
Presence of non-productive cough

2. Hyperthermia

F#2
D- Skin flush and warm to touch
Increase body temp to 39.1 C/ axilla

3. Fatigue

F#3
D- less movement with the verbalization para akong walang
lakas , nanghihina ako
----------------------------------------S/N A.J.Dela Cruz

6:00 am

8:00 am

NURSESS PROGRESS NOTE

A- monitored v/s and charted

Regulated I/V fluid and charted
Assessed pt. care needs and performed handwashing before
handling the patient
Morning care done
O2 inhalation via cannulla given @2lmp
Put on semi fowlers position
Advised to increased fluid intake
Promote proper ventilation and therapeutic environment
Provide comfort measure and opportunity to rest
Due meds given
------------------------------S/N A.J.Dela Cruz

General Guidelines for

Charting in the Progress
Notes
9.

In case with multiple problem in 1 shift

Date /Time

7/12/13
12:30pm
4:00pm

FOCUS

NURSESS PROGRESS NOTE

A- tepid sponged bath done

Advise to wear loose clothing
------------------------------S/N A.J. Dela Cruz
R- patient is resting comfortably in bed verbalizing
nabawasan ang hirap ng aking paghinga
Temp decrease to 37.7 C/axilla
RR decrease to 15 cpm
Able to cough out phlegm
------------------------S/N A.J. Dela Cruz

General Guidelines for

Charting in the Progress
Notes

10.

FDAR FORMAT For Discharge Patient

REMEMBER THIS ACRONYM

.

Discharge plan for Patient

.
.
.
.
.
.
.

M- medication
E- environment
T- to follow check up / referral
H-Health Teaching
O- other problems - guidance
D- diet/ nutrition
S- spirituality

Discharge Plan for patient

Undergo Surgery
H- Health Teachings
A- anticipatory Guidance
S- Spirituality
M- medication
I- incision in Care
N- nutrition
E- environment

General Guidelines for

Charting in the Progress
Notes
FDAR FORMAT For Discharge
Patient

10.

Date /Time

7/12/13
1:00 pm

2:00 pm

FOCUS

Discharge
Plan

NURSESS PROGRESS NOTE

D- Discharge order given by Dr. Magugat @11:00am
M - advised the patient and relatives to give/take the ff .
medicine @ the right time, dose, frequency and route
E - encourage to maintain cleanliness of the house and
surroundings
T- advised to go to the follow up consultation on the prescribed
date
H- encouraged to do chest clapping to facilitate mobilization of
secretion
-encourage to continue increase fluid intake to
liquify and
loosen secretion
O- observe for sign of infection such as fever, black fury
tongue and foul odor discharges
D- encouraged to eat fresh vegetable and fish
S- advise to continue praying to God and hear masses on
Sunday
-----------------------------------S/N A.J. Dela Cruz

Out of room per wheelchair with improved condition

-------------------------------S/N A.J. Dela Cruz

Transcribe the Narrative

Notes into Focus Notes
Date/Time

Notes

1/31/2013
8:15 am

Monitor shows bigeminy PVCs. B.P. 100/50. Denies chest

pain, nausea or shortness of breath. Skin warm and dry.
-----------------------------------------A. Nurse, RN
Lidocaine 75 mg IV push as per protocol. Lidocaine
infusion started at 2 mg/min. Dr. Smith notified - no new
orders.---------------------------------A. Nurse, RN
No further bigeminy PVCs on monitor, B.P.
110/62.---------------------------------------------A. Nurse, RN

8:20 am
8:30 am

Transcribe the Narrative

Notes into Focus Notes
Date /Time

1/31/2013
8:15 am

8:20 am

8:30 am

FOCUS

cardiac
arrhythmia

PROGRESS NOTE

D: Monitor shows bigeminy PVCs (see

rhythm strip). B.P. 100/50. Denies chest
pain, nausea or shortness of breath. Skin
warm and dry. -------------A.Nurse, RN
A: Lidocaine 75 mg I.V. push as per
protocol. Lidocaine infusion started at 2
mg/min. Dr. Smith
notified.---------------------------------------A.Nurse,
RN bigeminy PVCs on monitor
R: No further
B.P. 110/62. See rhythm
strip.-------------------------------------A. Nurse,
RN

DOCUMENTATION DOs and

donts
Dos

Donts

DO write your own observations and

sign over printed name. Sign and
initial every entry

DONT make or sign an entry for

someone else

DO describe patients behavior

DONT change entry because

someone tell you too.

DO use direct patient quotes when

appropriate

DONT try to cover up a mistake or

accident by inaccuracy or omission

DO factual and complete. Record

exactly what happens to patient and
care given.

DONT white out or erase an error

DO draw a single line thru an error

mark this entry as ERROR and sign
your name

DONT throw away notes with an

error on them

DOCUMENTATION DOs and

donts
Dos

Donts

DO use available line to chart

DONT leave space for someone

else who forgot to chart. DONT write
in the margin

DO document patients current

status and response to medical care
and treatments.

DONT use meaningless words and

phrases, such as good day or no
complaints

DO write legibly. Do use standard

chart forms.

DONT use notebook, paper or pencil

DO use only approved abbreviation.

DONT begin charting until you check

the name and identifying number on
the patients chart on each page

DO time and date all entries. DO

read what other providers have
written before providing care and
before charting

DONT chart procedures or chart in

advance

THANK YOU !!!