To be able to understand the FDAR system

of documentation

To be able to write focus format progress
notes applicable to your health care
profession and practice setting.
Documentation is any written or electronically
generated information about a client that
describes the care or service provided to that
client
Written evidence of:

The interactions between and among health care
professionals, clients, their families, and health care
organizations.

The administration of test, procedures, treatments, and
clients education.

The results of, or clients response to, diagnostic tests and
intervention

A. TO FACILITATE COMMUNICATION

Nurses communicate to other nurses and care providers
their assessments about status of clients, nursing
interventions that are carried out and the results of these
interventions.

Thorough, accurate documentation decreases the potential
for miscommunication and errors


B. TO PROMOTE GOOD NURSING CARE

Encourage nurses to assess client progress and determine
which intervention are effective and which are ineffective,
and identify and document changes to the plan of care as
needed.

Facilitating nursing research, all of which have the potential
to improve the quality of nursing practice and client care.
C. TO MEET PROFESSIONAL & LEGAL STANDARDS

Documentation is a valuable method for demonstrating
that, within the nurse-client relationship, the nurse has
applied nursing knowledge, skills and judgment according
to professional standards.

The nurses documentation may be used as evidence in
legal proceedings such as lawsuits, coroners inquests, and
disciplinary hearings through professional regulatory
bodies.


Focus Charting describes the patients perspective and
focuses on documenting the patients current status,
progress towards goals and response to interventions.

With this system of documentation, the nurse identifies a
focus based on client concerns or behaviors determined
during the assessment.

Format is easy to learn.

Useful way to organize patient progress notes.

Provides easy, quick information retrieval.

Facilitates documentation of all information needed to meet
professional and accreditation standards.

Supports multidisciplinary clinical collaborative practice by focusing
on the patient and promoting communication.

Supports professional critical thinking.

Decreases duplication of information on the health record.

Decreases time spent in charting especially if used in conjunction
with a well designed, comprehensive flow sheet.




F

FOCUS
Problem identified from the patient. Identifies the
content or purpose of the narrative entry and is
separated from the body of the notes in order to
promote easy data retrieval and communication.

D

DATA
Is the subjective and/or objective information
supporting the stated focus or describing the
observations at the time of a significant event

A

ACTION
Immediate or future nursing actions based on the
nurses assessment/evaluation of the clients
condition.

R

RESPONSE
Describes the patient outcome/response to
interventions or describes how
goals have been attained.
REFERS TO EXAMPLE
A sign or symptom Hypotension, or Chest Pain
A patient behavior Inability to ambulate
An acute change in the patient
condition
Respiratory distress, code blue,
diabetic coma
A significant event in the patients
therapy
Surgery ( Appendectomy),
Transfusion of packed RBC
A special need Discharge Planning Need, Family
conference
medical diagnosis PVCs (or other cardiac
arrhythmias), hyperbilirubinemia -
Competent R.N.s in ICU

Enter a focus note only when it is required.
Do not write a focus note because its time (end of shift), or
because you want to indicate that you observed the patient at
regular intervals.
Remember, the goal is to communicate essential patient
information.
To assist you in choosing a focus, ask yourself What is the
focus of my care or concern for this patient? Is this the main
topic of the note? Is it patient related and not treatment
related? Is it specific? (e.g., right ankle edema instead of
edema)

no

FOCUS

ACTIVE

RESOLVED

REINSTATED

DISCIPLINE

1.

Ineffective airway clearance

7/20/2013

7/22/2013

Nursing / RT

2.

Anxiety re: financial concern

7/22/2013



Social Worker

3.

Inadequate Intake of food


7/22/2013





Dietetian

4.

Spiritual Distress

7/22/2013

7/23/2013

Pastoral Care
Date/Time FOCUS PROGRESS NOTE

DATA: Staring out window, refused to
eat lunch, states Just leave me
alone.---------------------------
ACTION: Patient and wife informed of
Cancer Support Group available in
hospital. Arrangements made with
chaplain to speak to patient this
afternoon.--------------K. Miller, SW


acute
grieving,
emotional
status
Date/Time FOCUS PROGRESS NOTE


DATA: states bowel movements are
hard and difficult to pass. Has had no
BM for 3 days. --------------------
ACTION: encouraged to drink plenty of
fluids, eat more fruits and vegetables
and exercise more.-----------------
RESPONSE: states will try above
measures and let staff know if has any
results on next visit. -----S. Smith RN


Constipation,
bowel
elimination

Charting in these categories completes the
clinical decision-making cycle, organizes
the focus note, promotes critical thinking
and assists the writer to communicate to
other health professionals in a logical and
concise manner.
1. The words DATA or (D), ACTION or (A), RESPONSE or (R) are included
in the documentation of the progress notes to remind the writer of
complete documentation for each focus.

2. The words DATA, ACTION, and RESPONSE (or D, A, R, ) are written
along the left margin of the Patient Progress Notes in order that the
information in each category may be more easily located.

3. The full signature of the health care professional making the entry
should appear only at the end of the complete entry for the time
entered in the Date/Time column. This includes first initial, last name
and professional designation. e.g., A. J. Dela Cruz R.N.

Note: If a name stamp is used in a facilities standard patient chart,
then this should be used with signature above.
4. DATA and ACTION recorded at one time, RESPONSE is not added
until later, when patient outcome is evident.
Date /Time
FOCUS
NURSESS PROGRESS NOTE
1/31/2013

10:45 am





11:45am
1. rt. elbow
pain
F#1
DATA: Complains of stabbing right elbow
(operative) pain 7 on scale of 10.
ACTION: Demerol 50 mg. I.M., given in left
Ventero gluteal muscle.
RESPONSE: Resting in bed. States pain has
decreased to a level of 3 out of 10.------
------------------------C. Adams, RN
5. It may not be necessary to use all four categories (DATA,
ACTION, RESPONSE) with each FOCUS entry. These
categories are guides to organize the documentation, and
should be used only as relevant or reasonable. Any
combination of the categories can be used (only one, two,
three or all four) in the order that best communicates to
other health care team members.

6. RESPONSE is used alone to indicate a care plan goal has
been accomplished.
Date /Time
FOCUS
NURSESS PROGRESS NOTE
1/31/2013

10:45 am
1. patient
teaching
dressing
change
F#1
RESPONSE: Demonstrated independent
change of his abdominal dressing correctly
using aseptic technique. -----W.Green, RN
EXAMPLE:
6. DATA or DATA & Response is used alone when the purpose of a note
is to document assessment findings.

EXAMPLE #1

Date /Time
FOCUS
NURSESS PROGRESS NOTE
7/12/13

2:00 pm
Return from
P.A.C.U
DATA: Received via stretcher, awake and
alert, vital signs stable (see graphic record). IV
right forearm patent (see fluid balance record).
Foley catheter intact draining clear yellow
urine, dressing RLQ dry and intact, moving all
extremities voluntarily, states she has minimal
pain 3 out of 10. -----------------Y. See, RN
Date /Time
FOCUS
NURSESS PROGRESS NOTE
1/31/2013

10:45 am
Admission
Assessment
D- Receive from ER via stretcher,conscious,
coherent, with IV of 4PLR 1L + 8.25 meq KCl
@ 66 ugtts/min infusing well @ the R
forearm
on O2 vial nasal cannula @ 3 lmp.
V/S BP- 110/70mmHG, RR-26 cpm, PR- 90
bpm, T-36.9 celsius/axilla.

A- Transfer to room & orient to room set up-
-----------------S/N A.J. Dela Cruz
EXAMPLE #2:
7. Action and Response are repeated without additional data to
show the sequence of decision making based on evaluating
patient response to the initial intervention.


Date /Time
FOCUS
NURSESS PROGRESS NOTE
7/12/13

8:00 Am
Nausea
F#1
D- I feel like my stomach is feeling up with pressure
again and Im nauseated
Abdomen round and soft
Gastronomy bag at body level. Rare bowel sounds
A- gastronomy bag lowered
R- I feel like better now
Approximately 200cc golden fluid returned as much
flatus________________________S/N A.J.Dela Cruz
1:00PM A- Keep gastronomy bag at body level
Monitor abdominal status
Monitor how long bag is tolerated at body level
Document any discomfort
Patient instructed to call nurse when he is uncomfortable
R- I understand Plan
------------------------------S/N A.J. Dela Cruz
8. Begin the note with ACTION when the patient interaction begins
with intervention or when including date would be unnecessary
repetition

Date /Time
FOCUS
NURSESS PROGRESS NOTE
7/12/13

10:00 am
Health
Teaching
Digoxin
A- Patient instructed on the action and
side effect of digoxin.
Given digoxin information card
Discusses when he would call the physician
about the medicine
R- return demonstration of radial pulse
I understand the purpose of medication
---------------------S/N A.J. Dela Cruz
9. In case with multiple problem in 1 shift



Date /Time
FOCUS NURSESS PROGRESS NOTE
7/12/13

6:00 am
1. Ineffective
Breathing Pattern
F#1
D- increase respiratory rate of 24cpm
Use of accessory muscle to breath
Presence of non-productive cough
2. Hyperthermia F#2
D- Skin flush and warm to touch
Increase body temp to 39.1 C/ axilla
3. Fatigue F#3
D- less movement with the verbalization para akong walang
lakas , nanghihina ako
----------------------------------------S/N A.J.Dela Cruz
8:00 am A- monitored v/s and charted
Regulated I/V fluid and charted
Assessed pt. care needs and performed handwashing before
handling the patient
Morning care done
O2 inhalation via cannulla given @2lmp
Put on semi fowlers position
Advised to increased fluid intake
Promote proper ventilation and therapeutic environment
Provide comfort measure and opportunity to rest
Due meds given
------------------------------S/N A.J.Dela Cruz
9. In case with multiple problem in 1 shift



Date /Time
FOCUS NURSESS PROGRESS NOTE
7/12/13

12:30pm
A- tepid sponged bath done
Advise to wear loose clothing
------------------------------S/N A.J. Dela Cruz
4:00pm
R- patient is resting comfortably in bed verbalizing
nabawasan ang hirap ng aking paghinga
Temp decrease to 37.7 C/axilla
RR decrease to 15 cpm
Able to cough out phlegm
------------------------S/N A.J. Dela Cruz
10. FDAR FORMAT For Discharge Patient

REMEMBER THIS ACRONYM

Discharge plan for Patient Discharge Plan for patient
Undergo Surgery

M- medication H- Health Teachings
E- environment A- anticipatory Guidance
T- to follow check up / referral S- Spirituality
H-Health Teaching M- medication
O- other problems - guidance I- incision in Care
D- diet/ nutrition N- nutrition
S- spirituality E- environment

10. FDAR FORMAT For Discharge Patient




Date /Time
FOCUS NURSESS PROGRESS NOTE
7/12/13

1:00 pm
Discharge Plan
D- Discharge order given by Dr. Magugat @11:00am
M - advised the patient and relatives to give/take the ff .
medicine @ the right time, dose, frequency and route
E - encourage to maintain cleanliness of the house and
surroundings
T- advised to go to the follow up consultation on the prescribed
date
H- encouraged to do chest clapping to facilitate mobilization of
secretion
-encourage to continue increase fluid intake to liquify and
loosen secretion
O- observe for sign of infection such as fever, black fury tongue
and foul odor discharges
D- encouraged to eat fresh vegetable and fish
S- advise to continue praying to God and hear masses on
Sunday
-----------------------------------S/N A.J. Dela Cruz
2:00 pm
Out of room per wheelchair with improved condition
-------------------------------S/N A.J. Dela Cruz


Date/Time


Notes

1/31/2013
8:15 am

8:20 am


8:30 am
Monitor shows bigeminy PVCs. B.P. 100/50. Denies chest
pain, nausea or shortness of breath. Skin warm and dry. --
---------------------------------------A. Nurse, RN
Lidocaine 75 mg IV push as per protocol. Lidocaine
infusion started at 2 mg/min. Dr. Smith notified - no new
orders.---------------------------------A. Nurse, RN
No further bigeminy PVCs on monitor, B.P. 110/62.------
---------------------------------------A. Nurse, RN




Date /Time
FOCUS PROGRESS NOTE

D: Monitor shows bigeminy PVCs (see
rhythm strip). B.P. 100/50. Denies chest
pain, nausea or shortness of breath. Skin
warm and dry. -------------A.Nurse, RN

A: Lidocaine 75 mg I.V. push as per
protocol. Lidocaine infusion started at 2
mg/min. Dr. Smith notified.-------------
---------------------------A.Nurse, RN

R: No further bigeminy PVCs on monitor
B.P. 110/62. See rhythm strip.-----------
--------------------------A. Nurse, RN

1/31/2013
8:15 am
8:20 am
8:30 am

cardiac
arrhythmia

Dos Donts
DO write your own observations and
sign over printed name. Sign and initial
every entry
DONT make or sign an entry for
someone else
DO describe patients behavior DONT change entry because
someone tell you too.
DO use direct patient quotes when
appropriate
DONT try to cover up a mistake or
accident by inaccuracy or omission
DO factual and complete. Record
exactly what happens to patient and
care given.
DONT white out or erase an error
DO draw a single line thru an error
mark this entry as ERROR and sign
your name
DONT throw away notes with an error
on them
Dos Donts
DO use available line to chart DONT leave space for someone else
who forgot to chart. DONT write in the
margin
DO document patients current status
and response to medical care and
treatments.
DONT use meaningless words and
phrases, such as good day or no
complaints
DO write legibly. Do use standard
chart forms.
DONT use notebook, paper or pencil
DO use only approved abbreviation. DONT begin charting until you check
the name and identifying number on
the patients chart on each page
DO time and date all entries. DO read
what other providers have written
before providing care and before
charting
DONT chart procedures or chart in
advance