FDAR Charting (Medicine Ward)

Date Focus Data , Action, Response

March 8, 2017 Post endorsement D - GCS 3 ( E1 V1 M1),

0600H assessment on moderate high back
rest, with nasogastric
tube, with endotracheal
tube to mechanical
ventilator on simv
mode, with heplock at
left arm, on low salt low
fat commercialized
feeding via ngt. On do
not resuscitate with
waiver.
March 8, 2017 Hypotension D with blood pressure
0900H of 70/40.
A assessed patient,
vital signs taken and
recorded, placed on
trendeleburg, informed
Dr. T. kept monitored.
R with latest Blood
pressure of palpatory
0930H 60
March 8, 2017 Bradycardia D with heart rate of
0950H 48bpm
A Assessed, informed
Dr T, and no
intervention made she
verbalized , refer if
asystole.
March 8, 2017 Asystole R- zero blood pressure ,
0955H zero heart rate , zero
respiration , spo2
undetectable
A assessed , informed
Dr T. noted DNR status
long lead ECG done.
R Dr T pronounced
death
March 8 , 2017 Post mortem care D dr t pronounced
1020H death; noted doctors
order
A- verified Doctors
order, informed patient
on procedure, removed
contraptions. Fixed
accordingly
R post mortem care
rendered

March 9, 2017 hyperglycemia D with blood sugar of

0900H 298mg/dl
A assessed patient ,
vital signs taken and
recorded, informed Dr
B, advised patient not
to eat, administered
10units of glulisine via
subcut as ordered by
Dr.B monitored
accordingly
R with latest CBG of
1000H 165mg/dl
March 9, 2017 Difficulty of breathing D- patient verbalized
0700H nahihirapan akong
huminga, noted nasal
flaring, with Respiration
rate of 31 bpm.
A assessed patient,
maintained on
moderate high back
rest, administered
salbutamol+ipratorium
nebulization,
encouraged deep
breathing exercises,
0730H taught relaxation
techniques.
R ok na po ko as
verbalized by patient,
Respiration rate of
 20bpm.

March 10, 2017 Aspiration precaution D on diabetic diet with

0700H commercialized feeding
via nasogastric tube---
A- Assessed condition;
maintained on
moderate high back
rest; checked patency
and placement of
nasogastric tube; with
positive gurgling sound;
due feeding done as
order; all needs
attended; kept
monitored
R- No Aspiration Noted

Promotion of Effective D> with diagnosis of

Breathing Pattern Pleural Effusion Right
secondary to CAP HR, on
oxygen inhalation at 2
liters per minute via nasal
cannula, on moderate
high back rest; with
oxygen saturation of
96%-----
A> Assessed patient, vital
sign taken and recorded;
due nebulization done;
encourage deep
breathing exercises;
encourage to expectorate
secretions; maintain on
moderate high back rest;
kept monitored from time
to time------
R> with oxygen
saturation of 98%---------
03/14/17 1130H For Discharge D> May go home order
by Dr. T; 39 years old
female; status post
emergency
appendectomy with
1215H heplock at right
 hand.-------
A> Verified doctors
order; Inform Patient
regarding discharge.
Advised the relative to
settle their accounts,
1400H unused medications
returned to pharmacy in-
house for discharge;
Pharmacy clearance and
cover sheet was
forwarded to billing.
Instruct patient and
relative about the follow
up check up schedule and
take home medications;
copy of discharge
summary was given to
the patient.------------------
R> Patient and relative
understood all the
discharge instructions;
Patient was discharged in
stable
condition.----------------------
---------