FDAR

FOCUS CHARTING  ACTION describes the nursing interventions

 Describes the patient's perspective and (independent, basic and perspective) past,
focuses on documenting the patient's present or future
current status, progress towards goals and  RESPONSE describes the patient
response to interventions. outcome/response to interventions or
describes how the care plan goals have been
OBJECTIVES attained
 To easily identify critical patient issues/
concerns in the progress notes. FOCUS
 To facilitate communication among all  To describe a patient's problem/ focus/
disciplines concern from the care plan when the purpose
 To improve time efficiency with of the notes is to evaluate progress toward the
documentation. defined patient outcome from the plan of care.
 To improve concise entries that would not Examples:
duplicate patient information already  Self care
provided on flowsheet/ checklist.  Skin integrity
 Activity tolerance
GENERAL GUIDELINES
 Focus charting must be Evident at least once  To document an acute change in patient's
every shift. condition - when there has been an event of
 Focus charting must be patient- oriented not new patient condition
nursing task-oriented. Examples:
 Indicate the date and time of entry on the first  Respiratory distress
column.  Seizure
 Focus note written on the second column  Code blue
 Data, Action and Response on the third
column.  To document a significant event or unusual
 Sign name (e.g. M. Aquino, RN) for every episode in patient care - when (a)
time entry. responsibility for patient care changes from
 Document only patient's concern and / or plan one department to another (b) a significant
of care treatment. e' Intervention venlon took took
 Document patient's status on admission, for place.
every transfer to/from another unit or Examples:
discharge.  Admission Pre-(specify procedure)
 For eight hours shift, use blue or black ink for assessment
morning and afternoon shift, red ink for night  Post-(specify procedure) assessment
shift.  Pre-transfer assessment
 For twelve hours shift, use blue or black ink  Discharge planning
for morning and red ink for night shift.  Discharge status
 Transfusion RBC
FDAR  PRN medication required
 FOCUS identifies the content or purpose of
the narrative entry and is separated from the DATA
body of the notes in order to promote easy  statements contain objective and/or subjective
data retrieval and communication information
 DATA is the subjective and/or objective  Action statement contains only nursing
information supporting the stated focus or interventions (basic, perspective,
describing the observation at the time of a independent) past, present or future.
significant event.  Patient outcome are evident in the response
statements
 FDAR
Remember!
 Data, Action, Response only contain
information related to the focus, none of the
information is extraneous (e.g.: asleep,
watching TV, visitec by family)
 Response statements are documented after
PRN medications are administered.
 DATA and ACTION are responded at one
hour and RESPONSE is not added until later,
when the patient outcome is evident.

EXAMPLES OF FOCUS CHARTING

Begin the charting with ACTION when the

patient's interaction begins with intervention or
when including date would be unnecessary
repetition.
Response is used alone to indicate a care of plan
wherein goal has been accomplished

DATA - is used when the purpose of the note is to

document assessment finding and there is no flow DOCUMENTATION
sheet/checklist for that purpose DO's
 DO read what other providers have written
before providing care and before charting.
 DO time and date all entries
 DO use flow sheet/checklist. Keep
information on flow sheet/checklist current.
 DO chart as you make observations.
 DO draw a single line thru an error mark this
entry an "ERROR" and sign your name.
 DO use next available line to chart.
ACTION AND RESPONSE  DO document patient's current status and
 are repeated without additional data to response to medical care and treatments.
show the sequence of decision making  DO write legibly. DO use standard chart
based on evaluating patient response to forms.
the initial intervention  DO use only approved abbreviations.
 DO write your own observations and sign
over printed name. Sign and initial every
entry.
 DO describe patient's behavior.
 DO use direct patient quotes when
appropriate.
 FDAR
 DO be factual and complete. Record exactly
what happens to patient and care given

DON'T's
 DON'T begin charting until you check the
name and identifying number on the patient's
chart on each page
 DON'T chart procedures or chart in advance.
 DON'T clutter notes with repetitive or
frequently changing data already charted on
the flow sheet/checklist
 DON'T squeeze in a next entry or "leave
space" for someone else who forgot to chart.
 DON'T write in the margin.
 DON'T use meaningless words and phrases.
Such as "good day" or "no complaints".
 DON'T use notebook, paper or pencil.
 DON'T make or sign an observations and
sign over entry for someone else.
 DON'T change an entry because someone
told you to do so.
 DON'T label a patient or show bias
 DON'T try to cover up a mistake or accident
by inaccuracy or omission.
 DON'T "white out" or erase an error.
 DON'T throw away notes with an error on
them.