FDAR - Nurses Notes

FDAR – Focus Data Action Response

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FOCUS CHARTING - describes the patient's perspective and focuses on documenting the patient's current status, progress towards goals, and response to interventions.

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Purpose of Fdar charting • To easily identify critical patient issues/concerns in the Progress Notes. • To facilitate communication among all disciplines. • To improve time efficiency with documentation. • To provide concise entries that would not duplicate patient information already provided on flow sheet/checklist. When is Fdar necessary • To describe a patient problem/ focus/ concern from the care plan

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To document an activity or treatment that was carried out To document a new findings To document an acute change in patient's condition To identify the discipline making the entry as well as the topic of the note To describe all specifics regarding patient/family teaching

-To document a significant event or unusual episode in patient care Example: Admission Pre- (specify procedure) assessment Post- (specify procedure) assessment Pre-transfer assessment Discharge Planning Discharge Status Transfusion RBC Begin thrombolytic therapy PRN medication required -To identify an exemption to the expected outcome Example: Wheezes left base Nausea -To document an activity or treatment was not carried out -To best describe patient’s condition in relation to medical diagnosis

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Separate the topic words for the body of notes: a. Focus note written on the second column. b. Data, Action and Response on the third column. 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 teaching per shift. Hence, GENERAL NOTES ARE NOT ALLOWED! Document patient’s status on admission, for every transfer to /from another unit, or discharge. Follow the Do’s of documentation Use BLUE or BLACK ink of pen for AM and PM shift, RED ink for NIGHT shift.

Fdar charting Focus – 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. Data

- statements contain objective and/or subjective information.

Action – statements that contain nursing interventions (basic, perspective, independent) past, present or future. - it also contains collaborative orders Response – Evident patient outcomes or response INFORMATION FROM ALL THREE CATEGORIES (DATA,ACTION,RESPONSE) should be used only as they are RELEVANT or AVAILABLE. However, all appropriate information should be included to ensure complete documentation. DATA and ACTION are recorded at one hour, and RESPONSE is not added until later, when the patient outcome is evident.

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 be factual and complete. 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.

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DON'T make or sign an entry for someone else. DON'T change and entry because someone tells you. 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 taskoriented. Indicate the date and time of entry in the first column.

RESPONSE is used alone to indicate a care of plan goal has been accomplished

ACTION and RESPONSE are repeated without additional data to show the sequence of decision making based on evaluating patient response to the initial intervention.

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

Begin the note with ACTION when the patient's interaction begins with intervention or when including data would be unnecessary repetition.

Workshop No.1 Patient having severe midsternal chest pain, radiating down left arm. Sinus 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