Hello, I need your help with regards to Focus Charting or FDAR Charting. Though it has been implemented to other hospitals, the hospital where I work at is just implementing it next year. I am currently assigned in the Emergency Room where what we mostly do are hospital admissions, and most of the samples that I have researched are applicable to ward progress note charting.
Could you give me an example of how will you chart using FDAR if a patient, say, is pregnant and is admitted due to labor pains... And what will also be the format if the patient at ER has 2 complaints such as vomiting and abdominal pain? what will be your focus there??
So patient 1 is pregnant, having labor pains..
and patient 2 is experiencing vomiting with abdominal pain
Your help will be highly appreciated. Thanks!
Dec 28, '12
FDAR charting: Focus Data Action Response. FOCUS CHARTING- describes the patient's perspective and focuses on documenting the patient's current status, progress towards goals, and response to interventions.
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
Purpose of FDAR charting
1) To easily identify critical patient issues/concerns in the Progress Notes.
2) To facilitate communication among all disciplines.
3) To improve time efficiency with documentation.
4) To provide concise entries that would not duplicate patient information already provided on flow sheet/checklist.When is FDAR necessary
5) To describe a patient problem/ focus/ concern from the care plan
6) To document an activity or treatment that was carried out
7) To document a new findings
8) To document an acute change in patient's condition
9) To identify the discipline making the entry as well as the topic of the note
10) To describe all specifics regarding patient/family teaching
11) To document a significant event or unusual episode in patient care
DOCUMENTATION DO’S AND DONT’S
-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.
-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 repetitive or frequently changing data already charted on the flowsheet/checklist.
-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.
-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.
-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 for every time entry-Document only patient’s concern and/or plan of care e.g. healthteaching per shift.
Dec 28, '12
patient 2 is experiencing vomiting
D -patient states is unable to keep anything down for 24 hours and is just throwing up "yellow stuff".Color...pale,skin warm and dry, mucous membranes dry, tugor fair HR120, B/P 104/56, RR 22
A -IV started 0.9NS #20angio LAC bolus given of 500 cc's Compazine 10mg IV slowly.
R - patient states feels less nauseated, no vomiting. HR 84, B/P 110/56, RR18 urine obtained.