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 ------------------------------------------------------------ kb
v
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