FDAR Charting sample

Px: F
Diagnosis: Anophthalmia OD

F – Risk for injury

D – Anophthalmia OD
D – Loosening ocular prosthesis
A – Vital signs taken
A – Environment kept well lighted
A – Place clear of clutter
R – Patient is free of injury

Px: C
Diagnosis: Mature Cataract OS

F – Pre-operative care
D – For PHACO with PCIOL OS
A – Vital signs taken
A – Established rapport
A – Patient teaching
A – Pre-operative medication administered as ordered
A – Advised patient to be on NPO diet as ordered
A – Change patient into gown
A – Transferred to OR
R – Patient is referred accordingly to OR

Px: P
Diagnosis: Multiple facial fracture, Post-op Maxillomandibular Fixation, ORIF

F – Post-operative care (9th day)

D – Post ORIF, Maxillomandibular Fixation
A – Vital signs taken
A – Passive mouth opening exercise
A – Rest encouraged
R – No complaints of pain, swelling, discharge, and nausea