FDAR
FDAR
FDAR
Focus
Progress Notes
Ex:
7/17/2013
7:15am
Cephalocaudal assessment
a clinical manifestation
alteration in the condition
behavior change
Data
Action
Response
Data
As compared to the nursing process, it is similar to the assessment stage. In the data part, assessment clues like vital
signs, observable change in the condition and altered behavior are written. Assessment cues include both the
objective and subjective data.
Action
The action part is comparable to the planning and implementation stages of the nursing process, involving the current
and possible nursing actions. This can include interventions and procedures performed. It may also contain the
alterations necessary for the patients plan of care.
Response
The evaluation stage of the nursing process is like the response part of the charting. It gives the detailed and
accurate reaction of the patient to the nursing action done. This will also reflect the condition of the patient after the
interventions.
To
document
significant
event
or
unusual
episode
in
patient
care
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. healthteaching per shift.
Focus
Progress Notes
5/20/201
Pain
D:
08:00pm
A:
Administered Celecoxib
200mg IV
Encouraged
deep
breathing exercises and
relaxation techniques
Kept
patient
comfortable and safe
R:
relieved
Focus
Progress Notes
5/20/2010
Hyperthermia D:
8:00pm
Temperature of 38.9OC
via axilla
Skin is flushed and warm
to touch
A:
7:30pm
Administered 250mg IV
Paracetamol as per
doctors order
Encouraged adequate
oral fluid intake
Encouraged adequate
rest
R:
10:00pm
Temperature decreased
from 38.9 to 37.1 OC