78191430-FDAR-Sample PDF

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Focus Charting of F-DAR is intended to make the client and client concerns and strengths the focus of care. It is a method of organizing health information in an individual’s record. Focus Charting is a systematic approach to documentation. Three columns are usually used in Focus Charting for documentation:  Date and Hour;  Focus and;  Progress Notes. The progress notes are organized into (D) data, (A) action, and (R) response, referred to as DAR (third column). Here is an example of a format of Focus Charting or F-DAR Date/Hour 3/7/20108:00pm Focus of care, this may be:

Focus

Progress Notes DataActionResponse   

a nursing diagnosis a sign or a symptom an acute change in the condition behavior

 The Data Category The data category is like the assessment phase of the nursing process. It is in this category that you would be writing your assessment cues like: vital signs, behaviors, and other observations noticed from the patient. Both subjective and objective data are recorded in the data category. The Action Category The action category reflects the planning and implementation phase of the nursing prosess and includes immediate and future nursing actions. It may also include any changes to the plan of care. The Response Category The response category reflects the evaluation phase of the nursing process and describes the client’s response to any nursing and medical care. Focus Charting Samples Listed below are sample focus charting for different problems. Pain The focus of this problem is pain. Notice the way the D,A,R were written. Date/Hour Focus Progress Notes 5/20/20108:00pm Pain D:>Reports of sharp pain on the abdominal incision area with a pain scale of 8 out of 10>Facial grimacing>Guarding behavior>Restless and irritable A: >Administered Celecoxib 200mg IV >Encouraged deep breathing exercises and relaxation techniques >Kept patient comfortable and safe R: >Patient reports pain was relieved Hyperthermia Date/Hour Focus Progress Notes 5/20/20108:00pm Hyperthermia D:>Temperature of 38.9 OC via

axilla>Skin is flushed and warm to touchA:>Tepid Sponge Bath (TSB) done 7:30pm>Administered 250mg IV Paracetamol as per doctor’s order >Encouraged adequate oral fluid intake >Encouraged adequate rest R: 10:00pm>Temperature decreased from 38.9 to 37.1 OC Another Variation This is DAR made by Jay-D Man of Slideshare.net. with some modifications made. This is a very good variation. F1: Ineffective Breathing Pattern D1: increase respiratory rate of 24 cpm D2: use of accessory muscle to breath D3: presence of nonproductive cough F2: Hyperthermia D1: skin warm and flush to touched D2: increased body temperature of T= 38.9 degree celsius/axilla F3: Fatigue D1: less movement noted A: 9:00am  monitored v/s and charted  regulated IVF and charted  morning care done  assessed patient needs and performed handwashing before handling the patient  advised SO to always stay on patient bedside  promote proper ventilation and a therapeutic environment  elevated the head of the bed (moderate high back rest)  provided comfort measures and provide opportunity for patient to rest  due meds given 9:30am  tepid sponge bath done  instructed SO to provide blanket and let patient wear loose clothing F4: Discharge Plan (12:00nn) D1: discharged order given by Dr.Name/Time  M – advised SO to give the ff. meds at the right time, dose, frequency and route  E – encouraged to maintain cleanliness of the house and surroundings  T – advised to go to follow-up consultations on the prescribed date  H – encouraged to do chest tapping to facilitate mobilization of secretion  O – observed for signs of super infections such as fever, black fury tongue and foul odor discharges  D – encouraged to eat fresh vegetables and fish

S – advised to continue praying to God and hear mass on Sunday 2:00pm – out of the room per wheelchair with improved condition Conclusion Do you have another variation on how to do the F-DAR method? You can leave your comments below! References:  A very helpful guide on F-DAR or Focus Charting via SlideShare.net  Fundamentals of Nursing by Kozier and Erbs  Image Source from here ...