Focus Charting 3c5e1f

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. Focus Charting Parts Three columns are usually used in Focus Charting for documentation:   

Date and Hour Focus 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 3/7/2010 8:00pm

Focus Progress Notes Focus of care,  Data this may be:a  Action nursing  Response diagnosis a sign or a symptom an acute change in the condition behavior

Progress Notes Data (D) 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. Action (A) The action category reflects the planning and implementation phase of the nursing process and includes immediate and future nursing actions. It may also include any changes to the plan of care. Response (R) 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 (F-DAR) Samples

Listed below are sample focus charting for different problems. F-DAR for Pain The focus of this problem is pain. Notice the way how the D, A, and R are written. Date/Hour 5/20/201

Focus Pain

Progress Notes D: 

08:00pm

  

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:  



istered Celecoxib 200mg IV Encouraged deep breathing exercises and relaxation techniques Kept patient comfortable and safe

R: 

Patient reports pain was relieved

F-DAR for Hyperthermia Date/Hour 5/20/2010

Focus Progress Notes Hyperthermia D: 

8:00pm



Temperature of 38.9 OC via axilla Skin is flushed and warm to touch

A: 

Tepid Sponge Bath

(TSB) done 7:30pm 

 

istered 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 m 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

Name of patient: Villareal, Juanita F > Hyperthermia D > Received patient sitting on bed with bottle # 1D5NSS 1 liter @ 30gtts/min. at thelevel of 350cc, hooked at the right basalic vein, infusing well.

-38.5° PR-110bpm RR-38m BP-160/60mmHg A> Bedside care done.

>

Ambroxol 30mg 1 tab given p.o

nt positions on bed.

> Above IVF consumed and followed-up with bottle #2 D5NSS 1 liter regulated at30gtts/min.9:30pm >Cefuroxime 750mg given IVTT .10:00pm > Vital signs rechecked and recorded. R > Patient was able to maintain temperature within normal range, T-36.9°C

T-36.9 C;PR-100bpm RR-38m BP-170/70mmH

F> Ineffective airway clearance D> Received patient sitting on a chair with bottle # 3 PNSS 1 liter regulated at30gtts/min. at the level of 90cc, hooked at the left metacarpal vein, infusing well. inhalation via nasal cannula regulated at 1L/min. RR-28m

A> Bedside care done.

back dry. breathing .6:00pm .6:15pm

> Nebulization with Salbutamol 1 nebule done >

9:30pm .

>Cefuroxime 750mg given IVTT

0.3NaCl 1 liter at KVO rate.

>

Vital signs

rechecked and recorded. R> Patient was able to maintain effective airway clearance and had no complaintsof difficulty of breathing. me IVF at the level of 920cc. T-36.7°C; PR-87bpm RR-25m BP-120/80mmHg