FOCUS

CHARTING
FDAR
 FOCUS CHARTING
• describes the patient's perspective and
focuses on documenting the patient's current
status, progress towards goals, and response
to interventions.
 Purpose of FDAR charting
• To easily identify critical patient
issues/concerns in the Progress
Notes.
• To facilitate communication
among all disciplines.
• To improve time efficiency with
documentation.
• To provide concise entries that
would not duplicate patient
information already provided on
flow sheet/checklist.
• DATA
– Subjective and objective data that
supports the focus
– Assessment phase of the nursing
process

• ACTION
– Interventions, such as medication,
treatment, calls to the physician, and
patient teaching.
– Planning and implementation phase of
the nursing process

• RESPONSE
– Patient’s response to your
interventions
– Evaluation phase of the nursing
process
 What can be your focus?
1. A patient’s problem/focus or concern from the nursing
care plan-when the purpose of the note is to evaluate
progress toward the defined patient outcome.

• Example:
– skin integrity
– coping
– activity intolerance
– self-care deficit
– physical mobility
– tissue perfusion
– airway clearance
 DATE TIME FOCUS DAR
11/3/19 3:00PM Ineffective Airway D: >coarse crackles on right upper lung.
Clearance unable to bring up phlegm.
A: >placed on moderate high back rest.
>Nasotracheal suctioning done.
>Oxygenation at 2LPM as ordered via
nasal cannula.
R: >suctioned thick yellowish mucous
plenty in amount. Able to sleep after.
 What can be your focus?
2. A new finding– to document a new sign and
symptom or behavior which is the current focus
of care.
• Example:
– constipation
– Diarrhea
– Wheezes
– Hematoma
– Chest pain
– Nausea
– bleeding
 DATE TIME FOCUS DAR
11/3/19 4:30PM Chest Pain D: >patient complained of mid-sternal
pain radiating to the left, stabbing with
a pain scale of 7/10.
A: >hooked to cardiac monitor.
>Monitored v/s. oxygenation at 4LPM
via nasal cannula.
>Referred to ROD.
5:00PM >Medicated with Morphine SO4 10 mg
IV as ordered.
R:> rested in bed, v/s taken, BP 130/90
HR 78/min, regular rate and rhythm.
>Patient stated pain decreased to
rating of 3/10..
 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.
• Document only patient’s concern and/or plan of care
• Use BLUE ink of pen for AM, BLACK for PM shift, RED
ink for NIGHT shift.
 GENERAL GUIDELINES
• DO draw a single line thru an error. Mark this
entry as “error and sign your name.”
• DON'T clutter notes with repititive or
frequently changing data already charted on
the flowsheet/checklist.
• DON'T squeeze in a missed entry or “leave
space” for someone else who forgot to chart.
DON'T write in the margin
 DATE TIME FOCUS DAR
11/3/19 3:00pm Acute Pain D> Received lying on bed with ongoing 1st IVF of
PNSS1L X 120CC/HR at 360 cc level infusing well at
left metacarpal vein.
>With O2 inhalation at 2-4 LPM via nasal cannula.
>Poor skin turgor noted.
> Pain is rated as 4/10 and is localized on the
anterior chest. Characterized as pricking pain.
>Facial grimaces and guarding behaviors noted
when in pain.
A>Established rapport.
>Assessed pain level and characteristic.
>Assessed skin turgor.
>Cutaneous stimulation done.
>Provided quiet and calm environment.
>Positioned to comfort.
>Encouraged verbalization of feelings.
6:00pm >above IVF consumed and 2nd IVF of PNSS il x 16
hours replaced.
R> Pt. verbalized that pain is reduced from 4/10 to
2/10.
 DATE TIME FOCUS DAR
11/3/19 3:00pm Acute Pain D> Received lying on bed with ongoing 1st IVF of
PNSS1L X 120CC/HR at 360 cc level infusing well at
left metacarpal vein.
>With O2 inhalation at 2-4 LPM via nasal cannula.
>Poor skin turgor noted.
> Pain is rated as 4/10 and is localized on the
anterior chest. Characterized as pricking pain.
>Facial grimaces and guarding behaviors noted
when in pain.
A>Established rapport.
>Assessed pain level and characteristic.
>Assessed skin turgor.
>Cutaneous stimulation done.
>Provided quiet and calm environment.
>Positioned to comfort.
>Encouraged verbalization of feelings.
6:00pm >above IVF consumed and 2nd IVF of PNSS il x 16
hours replaced.
R> Pt. verbalized that pain is reduced from 4/10 to
2/10.
 DATE TIME FOCUS DAR
11/3/19 3:00pm Elevated Body D>>Received awake in a semi-fowler's
Temperature position.
>with intact and patent IFC connected to
urine bag draining to light yellow urine.
>With body temperature of 38.2oC per axilla.
>With flushed face and skin warm to touch.
A>Assessed patency of IFC.
>Assessed for signs of fever.
>TSB continuously done.
>Due medications given
>Offered fluids available at bedside.
>Removed extra clothings and blankets.
>Opened windows to enhance ventilation.
>Emphasized importance of increasing fluid
intake.
>Paracetamol 300mg stat thru IV as ordered
given
>Encouraged verbalization of feelings and
concerns
R>Temperature lowered from 38.2oC to 37oC.
 DATE TIME FOCUS DAR
11/3/19 3:00pm Elevated Body D>>Received awake in a semi-fowler's
Temperature position.
>with intact and patent IFC connected to
urine bag draining to light yellow urine.
>With body temperature of 38.2oC per axilla.
>With flushed face and skin warm to touch.
A>Assessed patency of IFC.
>Assessed for signs of fever.
>TSB continuously done.
>Due medications given
>Offered fluids available at bedside.
>Removed extra clothings and blankets.
>Opened windows to enhance ventilation.
>Emphasized importance of increasing fluid
intake.
TIME???? >Paracetamol 300mg stat thru IV as ordered
given
>Encouraged verbalization of feelings and
concerns
R>Temperature lowered from 38.2oC to 37oC.