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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 DOS AND DONTS DONTS


-DO time and date all entries. -DON'T begin charting until you check the name and
-DO chart as you make observations. identifying number on the patient's chart on each page.
-DO write your own observations and sign your own -DON'T chart procedures or cares in advance.
name. -DON'T make or sign an entry for someone else.
-DO describe patient's behavior and use direct patient -DON'T change and entry because someone tells you.
quotes when appropriate. -DON'T label a patient or show bias.
-DO record exactly what happens to patient and care -DON'T try to cover up a mistake or incident by
given. inaccuracy or omission.
-DO be factual and complete. -DON'T white out or erase an error.
-DO draw a single line thru an error. Mark this entry as -DON'T throw away notes with an error on them.
error and-sign your name. -DON'T squeeze in a missed entry or leave space for
-DO use only approved abbreviations-DO use next someone else who forgot to chart.
available line to chart. -DON'T write in the margin.
-DO document patient's current status and response to -DON'T use meaningless words and phrases, such as
medical care and treatments. good dayor no complaints-
-DO write legibly. DO use ink. DO use accepted chart -DON'T use notebook paper or pencil.
forms.
GENERAL GUIDELINES
-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 patients concern and/or plan of care e.g. health teaching per shift.

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