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FDAR

Focus
Data
Action
Response
WHAT AND WHY?
 Focus Charting describes the patient’s
perspective and focuses on documenting the
patient’s current status, progress toward goals
and response to interventions.

 It brings the focus of care back to the patient and


the patient’s concerns.
FOCUS
 This is the subject/ purpose for the note. The
focus can be:
*Nursing Diagnosis
*Event(Admission, transfer, discharge
teaching etc.)
*Patient event or concern (code blue,
vomiting, coughing)
-it may also include significant events such as
teaching, consultation, monitoring, management of
activities of daily living or assessment of functional
health patterns.
GENERAL GUIDELINES
 Focus charting must be evident at least one every
shift.
 Focus charting must be patient-oriented not
nursing task-oriented.
 Indicate the date and time of entry on the first
column
 Sign name (e.g Alyssa Anne C. agravante, RN.)
for every time entry.
 Document patient’s status on admission, for
every transfer to/from another unit or discharge.
Blue ink is used for
morning shift, Black ink
for afternoon shift and
red ink for night shift.
SPECIFIC GUIDELINES

Begin with comprehensive


assessment of the patient using
IPPA.
Establish a focus of care to be
addressed in the Progress Notes.
DData-
ATA, A CTION
this , RESPONSE
is written in narrative form and
contains only subjective and objective data.

 Action- contains nursing interventions


(dependent, independent and interdependent).

 Response- describes the patient


outcome/response to interventions or describes
how the care plan goals have been attained.

*information from all these categories should be


used only as they are relevant or available.
However all appropriate information should be
included to ensure complete documentation
DO’S AND DONT’S
Do’s

 Do read what other  Don’t begin charting until


you check the name and
providers have written identifying number on the
before providing care patient’s chart on each
and before charting page.
 Don’t chart procedures or
 Do time and date all chart in advance.
entries.  Don’t make or sign an
entry for someone else.
 Sign and initial every
 Don’t try to cover up a
entry. mistake or accident by
 Do describe patient’s inaccuracy or omission
behavior.  Don’t white out or erase an
error
 Do use direct patient’s  Don’t squeeze in a issed
quotes when appropriate. entry or “leave space” for
 Do be facual and complete. someone else who forgot to
chart. Don’t write in the
 Do draw a single line thru margin.
an error and mark this
entry as “mistaken entry”
and sign your name.
 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 standart chart
forms.
 Do use only approved
abbreviations

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