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Sample Fdar Charting

The document describes a patient's labor and delivery in the delivery room on 12/13/11, including details of cervical dilation, effacement, and station during the first stage of labor, as well as the second and third stages of labor culminating in the delivery of a baby boy via spontaneous vaginal delivery attended by the physician and nurses. The nurses monitored the patient's vital signs and contractions, assisted with procedures, coached the patient, and provided postpartum care including monitoring bleeding and encouraging breastfeeding.

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zcharina
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22K views2 pages

Sample Fdar Charting

The document describes a patient's labor and delivery in the delivery room on 12/13/11, including details of cervical dilation, effacement, and station during the first stage of labor, as well as the second and third stages of labor culminating in the delivery of a baby boy via spontaneous vaginal delivery attended by the physician and nurses. The nurses monitored the patient's vital signs and contractions, assisted with procedures, coached the patient, and provided postpartum care including monitoring bleeding and encouraging breastfeeding.

Uploaded by

zcharina
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as DOCX, PDF, TXT or read online on Scribd
  • Sample DAR Charting: Delivery Room
  • Detailed Chart Content: Observations and Procedures

SAMPLE DAR CHARTING: DELIVERY ROOM12/13/11 FOCUS: First stage of Labor in progress

1 PM D: Into labor room a 26 year old female, with chief complaints of lumbosacral pain
characterized as mild to moderate,occurring irregularly and relieved by walking.

G1Po, 40th weeks AOG. T-36.6 C, PR-78, RR-18, BP- 100/70. Uterine contractions occurring every
3-5 minutes of 30seconds to 1 minute duration. Mild to moderate discomfort. 1:30 PM, IE done
by__________ revealed 60% effacement, 4cms dilatation. Station-1. 1:35 PM, IVF of D5LRS 1 Liter
x 30 gtts inserted by _____________.

______________________________ Initials A: Vital signs taken and recorded, monitored uterine


contractions, changed patient's clothes to patient's gown. Assisted withIE and IVF insertion and
regulated to prescribed rate, perineal care done, 2 PM, Buscopan 1 tablet every hour started.
DBEdemonstrated. Instructed client to walk around the room.R: "Tumitindi ang sakit ng tiyan ko."
DBE done by patient when in pain. ______________ Initals4PM FOCUS: Second and Third LaborD:
Into DR per stretcher with ongoing IVF of _______ at ________ ml level. "Tulo9y tuloy na ang sakit."
4:05 pm, IE done

by ____________ revealed station-_______, _____% effacement, fully dilated. Uterine contractions


occurring every minute,duration- 55 seconds, interval-5 seconds. PErineal bulging noted. With
bloody show. BP-130/90, PR-90, RR-22. 4:15 pm,RMLE done by Dr. ______________, 4:16 pm, born
an alive baby boy via SVD attened by _______________, assisted by

_____________. 4:17 pm, Phenergan ____ ml given per IV by _____________.Wiping of baby dry by
___________, positioned newborn on mother's abdomen and breastfeedinginitiated by
RN ___________. 4:19 pm, placenta out by ____________ mechanism, complete. Evacuation of
uterine blood clots done

followed by episiorrhaphy. _______________ Initials A: 4:07 pm transffered and brought to the DR.
Positioned patient on DR bed, straps applied. Monitores vital signs. Coachingof patient done. Kept
newborn on mother's chest warm by ___________. Application of perineal pads after perineal
caredone. Newborn taken by RN __________, transferred patient to stretcher. 4:23 pm, towards
with student nurse

_____________. _____________Initials

Admitted a case of name, age, sex, GP from address due to labor


pains/prematurerupture of membranes/ pre-eclampsia/ eclampsia/ severe bleeding/
intrauterined e a t h /
p l a c e n t a
p r e v
t r a n s i t
d e l i v e r y .

F:
Labor pains/Altered comfort
D:
grimaced face noted, kept on massaging her back, strong regular contractionsobserved, profuse perspiration
noted, full cervical dilatation and effacement noted,increased respirations noted.
A:
ushered to delivey room, mounted on the delivery table, positioned in lithotomyposition, perineal preparation
done, aseptically placed leggings and baby's receiveron mother's abdomen, coached on how to bear down
properly, assisted resident
ond u t y d u r i n g e p i s i o t o m y, s u p p o r t e d p e r i n e u m p r o p e r l y, d e l i v e r e d a n a l i v e b a b y g e n d
e r a t t i m e , d e l i v e r e d t h e p l a c e n t a i n D u n c a n / S c h u l t z m e c h a n i s m a t t i m e , assisted
resident on duty on the manual exploration of the uterus, postpartum BPtaken:reading (admistered
Methergine 1 amp IM as ordered), put on a diaper
andc
l
e
a
n
d
u
s
t
e
r
,
e
n
c
o
u
r
a
g
e
to breastfeed baby, placed ice pack over hypogastrium, monitor vital signs.
R:
with well contracted uterus and slight vaginal bleeding, still for continuous postpartum care

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