Charting provides documented medical record of services provided during a patient’s

care which includes procedures performed, medications administered, diagnostic test

results and interaction between the patient and healthcare professionals. Nurses have a
huge responsibility to complete patient charting accurately, which is critical in preventing
medical errors, providing high-quality patient care, and protecting medical staff from
liability and malpractice claims.
F-DAR, also known as focus charting, is a method that nurses use to help them
concentrate on a particular patient issue, performance, or event. The four steps of the
nursing process are used in this type of documentation: assessment, planning,
implementation, and evaluation. One F-DAR charting is intended to be concise and is
only concerned with one specific issue or situation.
What does FDAR stands for?
F- FOCUS
• Subject/purpose for the note. It can be:
o Nursing diagnosis
o Event (admission, patient transfer, health teaching..)
o Patient Event or Concern (High Blood Pressure, Vomiting, abdominal
pain)
D-DATA
• Written in narrative form and only contains the subjective and objective cues
A-ACTION
• This is the planning and implementation stages of the nursing process.
• This includes the intervention and procedures performed to the patient
• It may also contain alteration to the patient’s plan of care
R-RESPONSE
• Gives a detailed and accurate reaction of the patient after the nursing care is
done
• Reflect the condition of the patient after the interventions

Parts of an FDAR Charting

There are three columns used in FDAR charting during documentation:
• Date and Time
• Focus
• Progress Notes
F-DAR Sample Charting

The following are examples of charting for the FDAR method:

DATE/SHIFT/TIME FOCUS PROGRESS NOTES

08/18/13 7-3pm

D: “I’m out of breath,” as verbalized. RR =

8:15am
30, SpO2 = 90%. Use of accessory muscles
when breathing. Slightly dyspneic.

A: Assisted on high backrest.

8:20am

Difficulty of Administered Oxygen inhalation at 6

8:50am Liters/min via face mask. Advised to do deep
Breathing
breathing exercise. Encouraged to avoid
strenuous activities.

R. RR = 18, SpO2 = 97%. Normal

spontaneous breathing
noted. Charity
11:45am
F. Marquez, R.N.

DATE/SHIFT/TIME FOCUS PROGRESS NOTES

 08/18/13 7-3pm D: “Nurse, I’m feeling dizzy. I can’t
stand on my own,” as verbalized.
8:55am Low Blood Pressure Blood pressure of 70/50 mmHg. Pale
and weak looking.

A: Assisted in the modified

Trendelenburg position. Advised to
wriggle legs on the bedside before
ambulating and to avoid sudden
9:15am change of position.

Regulated IVF at the prescribed rate.

Provided rest periods.

R: Blood pressure of 110/70mmHg.

10:30am No dizziness reported.

Charity F. Marquez, R.N.

2:45pm

SOAPIE Charting
The sections in a SOAPIE chart address different perspectives and types of information
that could influence a patient's treatment or provide additional context for future
healthcare providers. Because SOAPIE notes collect both qualitative and quantitative
information about a patient's treatment, you can use them to provide a detailed record of
a patient's progress during each appointment.
Subjective –Documentation should include what the patient says or information that
only the patient can provide personally. This should include perceived pain, symptoms
such as feelings of numbness or tingling, medical and family history, and allergies. This
information is gathered through asking the patient questions and is important to record
exactly as the patient reports.
Objective – Record what the nurse observes, hears, sees, and feels during the patient
assessment. The types of assessments performed is dependent on the facility the
patient is in (inpatient versus outpatient) and on the medical diagnoses and patient
complaints.
Analysis – After subjective and objective assessment data is collected, the nurse
should make an initial analysis of the patient’s condition and identify any appropriate
nursing diagnoses.
Plan – Once an initial nursing diagnosis has been identified, the nurse must create a
plan of action. This may include repositioning, requesting pain medication from the
providers, applying oxygen per protocol, or providing emotional support. The plan
should be patient-centered and based on the nursing diagnoses.
Implementation – After the plan of action has been decided, the actions (interventions)
should be put into motion. Sometimes, a nurse’s plan does not go exactly as planned
and that is to be expected. It is important to document all of the interventions performed,
and even the ones that were attempted.
Evaluation – Finally, the outcomes of the interventions need to be evaluated. The
evaluation often includes reassessing the patient. If the evaluation reveals that an
intervention did not work, a different plan may need to be made. Repeat the last few
steps as necessary until a satisfactory outcome is reached.

SOAPIE SAMPLE

So these are the types of documentation that are used by the nurses in the hospital. I’m
going to end this presentation with a saying if it wasn’t charted, then it didn’t happen.
Always remember that as nurses we should document every single thing that we do to
our patients during our shift. It tells a chronological story about their care and health status. It
allows for all team members to remain updated and connected on the plan of care for patients
and how the patient is responding to that plan