FOCUS CHARTING (FDAR)

Emvie Loyd P Itable, RN, MAN

Presenter
Adopted from: Dr. Adriel Arman Pizzara RN, MAN
 LEARNING OBJECTIVES
After 25-30 minutes of presentation, learners will be able to:
1. Define what focus charting is.
2. Enumerate the different documentation principles of writing an FDAR
3. Contrast the objectives in making an FDAR.
4. Point out the contents of focus charting
5. Adapt the guidelines in making as FDAR.
6. Differentiate the Do’s and Don'ts of FDAR
7. Infer on the sample FDAR as presented

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FOCUS
CHARTING
FDAR
 FOCUS CHARTING

• Describes the patient’s perspective and focuses on documenting the

patient’s current status, progress towards goals and response to
interventions
• It is a systematic approach to documentation, using nursing
terminology to describe individual’s health status and nursing action
• Brings the focus of care back tot eh patient and the patient’s
concerns.

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DOCUMENTATI
ON PRINCIPLES
FDAR CHARTING
 Documentation must be able to
determine:
1. When an event happened
2. What happened
3. To whom it happened
4. By whom it happened
5. Why it happened
6. The result of what happened

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 Continuation..
• Maintain confidentiality of all patient information
• Documentation will be retrievable
• Documentation is to be neat, legible, and non-erasable
• Records must be an accurate, true and honest account of
what occurred and when it occurred.

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 DOCUMENTATION
PRINCIPLES
Documentation contains Provides current, clear,
meaningful information and complete, concise,
avoids meaningless phrases, concrete, documentation
such as “good night” up and of the patient’s status with
about,” or usial day. the least possible
Information documented must duplication of information
be relevant

Documentation must be Avoid statements such

reflective of observation not as”appears to” and
unfounded conclusions. “seems to” when
describing
observations
Documentation must reflect
the assessment, planning,
implementation and
evaluation of patient care

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 Continuation..
• Documentation will contain all clinical observations, actions
taken by the health care providers, all treatments, as well as the
patient’s response to the care provided.
• Document in a timely manner, during or as soon as possible,
after the delivery of care. Never chart before the delivery of
care
• Chart in chronological order, documenting entries in sequence
of events.

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FOCUS
 Topics that may appear in the
FOCUS column:

1. Patient’s concerns and behaviors

2. Thérapies and réponses
3. Changes of condition
4. Significant events
5. Management of ADLs
6. Assessment of functional health patterns
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 FOCUS
1.) Document new sign or symptom or a new
behavior.

Examples:
- Constipation
- Chest Pain
- Disorientation to time, place & person
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 FOCUS
2.) Acute change in patient’s condition

Examples:
- Respiratory distress
- Seizure
- Code Blue
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 FOCUS
3.) Document responsibility for patient care changes:

From one shift to another

AM shift to PM shift
From one department to another
ER to ward; ICU to Ward ; OR to Ward;
Patient discharge.
from ward to discharge
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 FOCUS
SHIFT
- Receiving assessment
- Endorsing assessment
DEPARTMENT
- Admission
- Pre-Caesarean Section assessment
- Post-Debridement assessment
DISCHARGE
- Discharge Status
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 FOCUS
4.) Document a significant treatment/ intervention.

Examples:
- Transfusion RBC
- Antibiotic Therapy
- Catheterization
- Dressing Change
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 FOCUS
5.) Document an activity or treatment that was not
carried out.

Examples:
- Refusal of Physical Therapy
- Refusal of Antibiotic Therapy
- Refusal of IV insertion/re-insertion
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 FOCUS
6.) Evaluate progress of the nursing diagnosis
toward the defined patient outcome from the plan
of care.

Examples:
- Self Care
- Skin Integrity
- Activity Tolerance
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 FOCUS
7.) Describe all specific patient/family teaching

Examples:
- Health Teaching: Diet
- Health Teaching: Exercise
- Health Teaching: Digoxin

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 FOCUS
8.) Identify the discipline making the entry as well
as the topic of the note

Examples:
- Social service: financial assistance
- Dietitian: low fat diet
- Physical therapy: crutch walking
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 Focus..

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 FOCUS
• Focus notes are necessary to best describe the
patient’s condition in relation to medical diagnosis
– when the patient’s focus is the pathophysiology
rather than the patient’s response to the problem
(this happens most frequently in high technical
areas such as critical care

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 Focus..
DATA: Subjective and/or objective information supporting the stated
focus or describing observations at the time of significant events.

ACTION: Nursing Interventions performed, planned to be

performed, and or protocols and procedures initiated.

RESPONSE: Description of individual’s response to medical and/or

nursing care. Statement that the Action Plan of Care outcomes have
been attained or are progressing toward attainment.

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 REMEMBER!

Information from all these Data and Action are

categories (Data, Action and responded at one hour and
Response) should be used only as Response is not added
they are relevant to your focus or
available. However, all appropriate until later, when the
information should be included to patient outcome is
ensure complete documentation. evident.

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 OBJECTIVES IN MAKING FDAR

To improve time efficiency

with documentation
To easily identify critical To improve concise entries
patient issues or concerns in that would not duplicate
the progress notes patient information already
provided on the flow
sheet/checklist
To facilitate communication
among all disciplines

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 GENERAL GUIDELINES FOR
FDAR

Focus chart Focus Indicate the Separate the topic

BE

BE

INDICATE

SEPARATE
must be charting must date and time words from the
body notes
evident at be patient- of entry on
* Focus notes –
least once oriented not the first written on the 2nd
every shift nursing task- column column
oriented * Data, Action and
Response – 3rd
column

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 Continuation..
• Document only patient’s concern and/or plan of care (e.g.
health per shift, hence, general notes are not allowed)
• Document patient’s status on admission, for every transfer
to/from another unit and for discharge
• Follow the do’s of documentation
• For 8-hours shift, black ink for morning or blue for afternoon
shift, and red ink for night shift
• For 12-hours shift, use blue or black ink for morning shift, and
red ink for night shift
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 SPECIFIC GUIDELINES

Begin with comprehensive Include in the assessment, Establish a focus of care, to

assessment of the patient collection of information be addressed in the progress
using inspection, palpation, from the patient, family notes
percussion and auscultation existing health records such
as, checklist/flow sheet,
laboratory results

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 Documentation Do’s..
• DO write your OWN observations and sign over printed name.
Sign and initial every entry
• DO describe patient’s behavior
• DO use direct patient quotes when appropriate
• DO be factual and complete. Record exactly what happens to
patient and care given
• DO draw a single line through an error and mark this entry as
”ERROR” and sign your name
• DO use next available line to chart
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 Documentation Do’s..
• DO document patient’s current status and response to medical
care and treatments
• DO write legibly. DO use standard chart forms
• DO use only approved abbreviations.

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 Documentation Don’ts..
DON’T make or sign an entry for someone else
• DON’T MAKE OR SIGN

DON’T change an entry because someone told you to

• DON’T change

DON’T label a patient or show bias

• DON’T label

DON’T try to cover up a mistake or accident by inaccuracy or omission

• DON’T try

DON’T “white out” or erase an error

• DON’T erase
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 Documentation Don’ts..

1 2 3 4 5
• DON’T use
• DON’T throw • DON’T • DON’T write
away notes squeeze in a over the
meaningless
words and phrases
• DON’
with an error missed entry margin
on them or “leave
such as “good
day” or
T use
space” for “complaints pencil
someone else
who forgot to
chart

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Date/Time Focus Data, Action, Response

09/20/12 Chest Pain D: “Sumasakit and dibdib ko”

10 AM Midclavicular line pain of 4/5

Radiating to jaw. Relieved by

Rest. VS stable.--------------------NE

A: Encourage to rest on bed.

Medicated with Isordil 5mg.------NE

12 NN Chest Pain R: Resting in bed “Nabawasan ang

sakit ng dibdib ko.” Rating of 2/5.

 ACTION and RESPONSE are repeated without additional
Data to show sequencing

Date/Time Focus Data, Action, Response

09/20/12 Fever D: “Init akong paminaw ”. Skin warm
10 AM to touch. Temperature is 39°C. ---SD
A: Tepid sponge bath given. -------SD
Encouraged to Increase fluid intake.
Referred to Dr. Tan. Paracetamol
500mg 1 tab. po given. --------------SD
12 NN Fever R: “Ginasingot nako.” Temperature
is 38°C. Tolerated 2 glasses of water
A: Continue tepid sponge bath.
Changed clothing. Monitor
temperature. ---------------------------SD
2 PM Fever R: Temperature is 37.2°C. “Dli na init
akong paminaw. Skin is cool to touch
DATA is used alone when the purpose of the note
is to document assessment finding and there is no
flowsheet/ checklist for that purpose

Date/Time Focus Data, Action, Response

09/20/12 Post- D: Received from RR via Stretcher,
10 AM Appendectomy awake and alert, VS stable, IV right
Assessment forearm, patent,foley in place with
Clear yellow urine, dressing on RLQ
is clean and dry, Moving all
extremities voluntarily. “Minimal
Incisional Pain at this time, rating of
3/5.” -------------------------------------CM
 Begin the note with ACTION when the patient's
interaction is being with the intervention or when
including data would be unnecessary repetition.

Date/Time Focus Data, Action, Response

09/20/12 Health A: Patient instructed on the Actions
10 AM Teaching: and side effects of Digoxin. Given
Digoxin digoxin information card/literature.
Discussion when He would call
the physician about the medicine.
R: Return demonstration of
Radial pulse. “I understand
Purpose of medication.”
RESPONSE is used alone to indicate a care plan
goal has been accomplished.

Date/Time Focus Data, Action, Response

09/20/12 Hypogastric R – Pain scale is 0/10. No guarding
Pain
10 AM of affected site. “ Naulian nako sa
Sakit sa akong tiyan”.-------------PLL
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“ Focus charting is not an

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act, it is a habit.

PRESENTATION TITLE
” 41