THE COLLEGE OF MAASIN

Nisi Dominus Frustra

College of Nursing and Allied Health Sciences

A guide to FOCUS CHARTING

FDAR charting: 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. It is a method for organizing health information in the individual's
record. It is a systematic approach to documentation, using nursing terminology to describe
individual's health status and nursing action. Focus • a key word or diagnostic category from a
nursing diagnosis or collaborative problem on the plan of care (action plan), i.e. skin integrity,
coping, activity tolerance, self care deficit • a current individual concern or behavior, i.e. nausea,
chest pain, pre-op teaching, hospital admission • a sign or symptom of (possible) importance to
the nursing and/or medical diagnosis or treatment plan, i.e. fever, constipation, hypertension,
incontinence, lethargy • an acute change in an individual's condition, i.e. respiratory distress,
seizure, fever, discomfort • a significant event in an individual's care, i.e. begin treatment
regimen (oxygen), change in diet, catheterization • a key word or phrase indicating compliance
with a standard of care or agency policy, i.e. self medication teaching plan, transition

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

Purpose of FDAR charting

1) To easily identify critical patient issues/concerns in the Progress Notes.
2) To facilitate communication among all disciplines.
3) To improve time efficiency with documentation.
4) To provide concise entries that would not duplicate patient information already provided on
flow sheet/checklist.
When is FDAR necessary:
5) To describe a patient problem/ focus/ concern from the care plan
6) To document an activity or treatment that was carried out
7) To document a new findings
8) To document an acute change in patient's condition
9) To identify the discipline making the entry as well as the topic of the note
10) To describe all specifics regarding patient/family teaching
11) To document a significant event or unusual episode in patient care

DOCUMENTATION DO’S AND DONT’S

-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.

DONT’S
-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 repetitive 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 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 for every time entry-Document only patient’s concern and/or plan of care e.g. health
teaching per shift.
 FDAR Charting Sample

DATE AND TIME FOCUS DATA, ACTION, RESPONSE

12/30/14 8:00pm Post-operative D - S/P radical prostatectomy; with dressing
over
care incision site on hypogastric area, dry & intact;
with
foley catheter attached to urometer, draining
well;
with Jackson Pratt, draining sanguineous fluid;
total
JP output for previous shift: 34cc; ongoing IVF
of
D5NR1L x 8hrs at right hand infusing well --------
---kbv
8:10pm A - Initial VS taken: 140/80mmHg, 83bpm,
21cpm,
37.2'C----------------------------------------------------------
--kbv
8:15pm A - Monitored JP output: 11cc-----------------------
---kbv
8:25pm A - Monitored urine output every hour------------
---kbv
8:30pm Safety and D - With complaints of minimal pain over
incision
comfort site, graded 4/10; no grimace; tolerable --------
---kbv
8:35pm A - Encouraged deep breathing exercises -----
-- kbv
A - Assisted to a comfortable position ------------
-- kbv
A - Encouraged diversional activities -------------
-- kbv
8:45pm A - Placed call light within reach -------------------
--- kbv
A - Instructed to call nurses station if in need of
assistance ---------------------------------------------------
- kbv
A - Instructed to maintain the side rails up
when in
bed------------------------------------------------------------
-- kbv
9:15pm Cough D - Complaints of dry cough, with increased
pain
on incision site during episodes 6/10 --------------
--- kbv
A - Instructed to use pillows as splint on incision
site
when coughing -------------------------------------------
- kbv
 A - Lozenges taken, care of patient ---------------
-- kbv
9:50pm R - Reassessed patient: states slight relief of
throat,
------ o v e r -------
------ c o n t I n u e d -------
decreased episodes of cough ----------------------
- kbv
10:10pm Inadequate D - Urine output 45cc for this hour, dark yellow
in
urine output color ----------------------------------------------------------
-- kbv
A - Provided alternating warm&cold
compress-kbv
A - Dr. C informed through SMS ---------------------
--- kbv
10:20pm A - Fast drip 200cc IVF ----------------------------------
-- kbv
11:00pm A - Urine output for this hour: 38cc -----------------
--- kbv
A - Dr. C informed ----------------------------------------
-- kbv
11:20pm A - Fast drip 200cc IVF ----------------------------------
-- kbv
12/30/14 12:00am Safety and A – Seen patient resting comfortably -------------
-- kbv
comfort A – Provided adequate rest periods --------------
--- kbv
A – Provided environment conducive for
sleep-- kbv
12:10am Post-operative A – Monitored JP drain: 9cc---------------------------
-- kbv
12:20am care A – Urine output: 45cc-----------------------------------
-- kbv
A – Furosemide(Lasix)20mg IV given as
ordered- kbv
1:00am R – Urine output: 58cc ----------------------------------
-- kbv
R – Monitored for the further recurrence of
output
inadequacy ------------------------------------------------
- kbv
1:45am A - Seen patient asleep --------------------------------
-- kbv
2:10am Pain A – Patient complaints of pain on IV site,
graded
6/10, swollen upon inspection -----------------------
-- kbv
2:15am A – Placed warm compress on area for
15mins – kbv
2:30am A – Reassessed patient, still with 6/10 pain ------
--- kbv
2:40am A – Informed MROD through SMS ------------------
--- kbv
A – Continued present management ------------
-- kbv
------ o v e r -------
------ c o n t I n u e d -------
3:10am A – With increasing pain, graded 7/10 -----------
--- kbv
3:20am A – Informed MROD -------------------------------------
-- kbv
4:00am R – Changed IV site to left hand; with IVF
infusing
well; with no complaints of pain in new site;
3/10
over previous site -----------------------------------------
-- kbv
4:15am A - Drained JP: 8cc --------------------------------------
-- kbv
5:00am Post-operative A – Seen patient, not in any distress, no
subjective
care complaints -------------------------------------------------
-- kbv
5:40am A – CBG taken: 118mg/dl -----------------------------
-- kbv
6:00am R – With stable vital signs: 130/80mmHg,
80bpm,
19cpm, 37.4'C; With dressing dry & intact; foley
catheter draining well; total JP output for
entire
shift: 28cc, draining sanguineous fluid ------------
-- kbv
Safety and R – Patient comfortable, no untoward incident
comfort during entire shift -----------------------------------------
-- kbv

kbvicente
Kerstin Karen B. Vicente,
RN
Lic. No. 766245

R – Endorsed patient to -------, RN for continuity

of
care------------------------------------------------------------
- kbv