ALTERNATIVE FLEXIBLE

LEARNING- RLE

labor room and delivery room

(LR-DR)

STEPHANIE B. GOGOLA, RM, RN, MAN

Clinical Instructor
 FOCUS CHARTING/ F-DAR

- is a method for organizing health

information in the individual's
record.
- is intended to make the client and
client concerns and strengths the
focus of care.
it is a systematic approach to
documentation, using nursing
terminology to describe
individual's health status and
nursing action.
Focus Charting Parts
Three columns are usually used in Focus
Charting for documentation:
 Date/ Shift/ Time
 Focus
 Progress Notes
The progress notes are organized into
(D) data, (A) action, and (R) response,
-referred to as DAR (third column).
FOCUS (F)

- focus of care
- this may be: a nursing diagnosis,
a sign or a symptom,
an acute change in
the condition
behavior.
DATA (D)

- the data category is like the assessment

phase of the nursing process.
- it is in this category that you would be
writing your assessment cues like: vital
signs, behaviors, and other observations
noticed from the patient.
- both subjective and objective data are
recorded in the data category.
ACTION (A)

- the action category reflects the

planning and implementation phase of
the nursing process and includes
immediate and future nursing actions.
RESPONSE (R)

- the response category reflects the

evaluation phase of the nursing process
and describes the client’s response to
any nursing and medical care.
 Date / Shift/ Time Focus Progress Notes

Data
Action
Response

Date/ Shift/ FOCUS DATA ACTION RESPONSE

Time
 Date/ Shift/ FOCUS DATA ACTION RESPONSE
Time
May 05, 2020 First Stage of - in to labor room 26 - changed patient’s
7-3 Labor in y/o, F/M with chief clothes to patient’s
8am Progress complaint of LSP gown.
characterized as - vital signs taken - within normal limits
moderate, occuring and recorded.
regularly, not - IE done
relieved by walking. - IVF of D5LR - patent; infusing well
- V/S inserted at right
- duration and metacarpal vein,
interval of regulated at 30
contractions gtts/min
- IE - assisted during
perineal care.
- “Humihilab po ang - instructed on - verbalized
tyan ko at masakit proper breathing understanding
tagos hanggang techniques
balakang. May - progress of labor
lumabas na din po monitored
sakin na dugo”, as - FHT monitored - within normal limits
verbalized by the
patient. _______________ - Name and Signature