FDAR – Focus Data Action Response - Separate the topic words for the body of notes:

a. Focus note written on the second column.

FOCUS CHARTING - describes the patient's perspective and focuses on b. Data, Action and Response on the third column.
documenting the patient's current status, progress towards goals, and
response to interventions.
- Sign name ( e.g. Geraldine M. Amiscaray, RN or G. Amiscaray,
RN) for every time entry
- Document only patient’s concern and/or plan of care e.g. health
Purpose of Fdar charting
teaching per shift. Hence, GENERAL NOTES ARE NOT ALLOWED!
• To easily identify critical patient issues/concerns in the Progress
- Document patient’s status on admission, for every transfer to
Notes.
/from another unit, or discharge.
• To facilitate communication among all disciplines. - Follow the Do’s of documentation
• To improve time efficiency with documentation. - Use BLUE or BLACK ink of pen for AM and PM shift, RED ink for
• To provide concise entries that would not duplicate patient NIGHT shift.
information already provided on flow sheet/checklist.
When is Fdar necessary Fdar charting
• To describe a patient problem/ focus/ concern from the Focus – identifies the content or purpose of the
care plan narrative entry and is separated from the
• To document an activity or treatment that was carried out
body of the notes in order to promote easy
data retrieval and communication.
• To document a new findings
Data - statements contain objective and/or
• To document an acute change in patient's condition subjective information.
• To identify the discipline making the entry as well as the
topic of the note Action – statements that contain nursing
• To describe all specifics regarding patient/family teaching interventions (basic, perspective,
independent) past, present or future.
-To document a significant event or unusual episode in patient care - it also contains collaborative orders
Example: Admission
Pre- (specify procedure) assessment Response – Evident patient outcomes or
Post- (specify procedure) assessment response
Pre-transfer assessment
Discharge Planning INFORMATION FROM ALL THREE CATEGORIES (DATA,ACTION,RESPONSE)
Discharge Status should be used only as they are RELEVANT or AVAILABLE.
Transfusion RBC However, all appropriate information should be included to ensure
Begin thrombolytic therapy complete documentation.
PRN medication required
-To identify an exemption to the expected outcome DATA and ACTION are recorded at one hour, and
Example: Wheezes left base RESPONSE is not added until later, when the patient outcome is evident.
Nausea
-To document an activity or treatment was not carried out
-To best describe patient’s condition in relation to medical diagnosis

DOCUMENTATION DO’S AND DONT’S

DO
- DO time and date all entries.
- DO use flowsheet/ checklist. Keep information on
flowsheet/checklist current. DO chart as you make observations.
- DO write your own observations and sign your own name. Sign
and initial every entry.
- DO describe patient's behavior and use direct patient quotes
when appropriate.
- DO record exactly what happens to patient and care given. DO RESPONSE is used alone to indicate a care of plan goal has been
be factual and complete. accomplished
- DO draw a single line thru an error. Mark this entry as “error and
sign your name.”
- DO use only approved abbreviations
- DO use next available line to chart.
- DO document patient's current status and response to
medical care and treatments.
- DO write legibly. DO use ink. DO use accepted chart
forms.
DONT’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 cares in advance.
- DON'T clutter notes with repititive or frequently changing data
already charted on the flowsheet/checklist.
ACTION and RESPONSE are repeated without additional data to show the
- DON'T make or sign an entry for someone else. DON'T change sequence of decision making based on evaluating patient response to the
and entry because someone tells you. initial intervention.
- DON'T label a patient or show bias.
- DON'T try to cover up a mistake or incident by inaccuracy or
omission.
- DON'T “white out” or erase an error. DON'T throw away notes
with an error on them.
- DON'T squeeze in a missed 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.

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.
 STAT & PRN MEDICATION

DATA is used alone when the purpose of the note is to document

assessment finding and there is no flowsheet /checklist for that purpose
NOTIFICATION OF PHYCISIAN

Workshop No.1
Begin the note with ACTION when the patient's interaction begins with
Patient having severe midsternal chest pain, radiating down left arm. Sinus
intervention or when including data would be unnecessary repetition.
tachycardia on monitor with occasional PVC noted.Morphine SO4 4mg IV
given.Restless. BP160/90 mmHG. Teary eyed and saying “Sakit na gyud
kaayo ang akong dughan”. Valium 5mg po given.

Output no.1

ADMISSION

Workshop No. 2
At 6pm, when the nurse entered the room she found the patient on the
floor between the bed and IV stand. When the patient saw the nurse, she
stated “Tabangi ko mam, nahulog ko.” Active bleeding from nose and some
blood in mouth. Tranexamic Acid 500 mg given.

Output 2
REASSESSMENT

DISCHARGE
Workshop No. 3
At 8:30 am, the nurse noted the patient was gasping for air, not responding
to verbal stimuli. Rales heard in all lung fields. A stat dose of Lasix 40mg IV
was ordered. After 30 minutes respiratory distress and diaphoresis were
noted. Skin remained pale. No change in LOC.

Output 3