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F-Dar, Focus Charting - Presentation Transcript

1. DEFINITIONS: o Focus Charting - is a method for organizing health information in the individual's record. It is a systematic approach to documentation, using nursing terminology to describe individual's health status and nursing action. o Focus o a key word or diagnostic category from a nursing diagnosis or collaborative problem on the plan of care (action plan), i.e. skin integrity, coping, activity tolerance, self care deficit o a current individual concern or behavior, i.e. nausea, chest pain, pre-op teaching, hospital admission o a sign or symptom of (possible) importance to the nursing and/or medical diagnosis or treatment plan, i.e. fever, constipation, hypertension, incontinence, lethargy o an acute change in an individual's condition, i.e. respiratory distress, seizure, fever, discomfort o a significant event in an individual's care, i.e. begin treatment regimen (oxygen), change in diet, catheterization o a key word or phrase indicating compliance with a standard of care or agency policy, i.e. self medication teaching plan, transition 2. COMPONENTS OF A FOCUS NOTE: o Data: Subjective and/or objective information supporting the stated focus or describing observations at the time of significant events. o Action: Nursing interventions performed, planned to be performed, and/or protocols and procedures initiated. o 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. 3. o Example: o Need: Comfort (or, Relief of pain ) D - Complaining of continuous, sharp pain in mid-abdominal incisional area. Crying. "I need something for pain now!" States pain is 9 on a scale of 10. A - Medicated with Demerol 75mg IM in LUOQ of left buttock. Repositioned on right side with pillow to abdomen to help splint wound. R - Patient stated pain was "much better" 30 minutes later and rated it 3 on a scale of 10.---N. Nurse 4. General Survey o Appearance of the patient, condition- when seeing the patient o Any IVF or Medications attaches to the arms of the patient o Current Vital Signs of the Patient o Eg.

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Approached sitting on bed, awake, responsive, coherent with ease in respiration, with O2 at 2 LPM, with an IVF of 4 PLR 1L + 8.25 meq KCl @ 66 ugtts/min infusing well at the Right arm, with the following V/S: BP= 110/70 mmHG, PR= 100 bpm, RR= 26 cpm, T= 36.8 degree Celsius/axilla. Followed by F-DAR After writing the F-DAR , at the end of the shift write again your general observation/survey of the patient condition 5. F: Hyperthermia D: > increase in body temperature above normal range to T= 38 degree Celsius/axilla > flushed skin and warm to touched A: 9:00am > Tepid sponge bath done > instructed SO to let patient wear loose clothing > instructed SO to provide blanket to patient when shiver > instructed SO to let patient drink lots of fluid > instructed SO to include in his diet foods rich in Vitamin C such as oranges > provided opportunity for patient to rest > due meds given R: 1:00pm > patient was able to rest > patient temperature decrease to T= 37.8 degree Celsius/axilla 6. 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= 37.7 degree celsius/axilla F3: Fatigue D1: less movement noted with the verbalization of kapoy man ako lawas, kulangan ko ug katulog 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 7.

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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 8. Discharge plan for patient who undergo Surgery H Health Teachings A Anticipatory Guidance S - Spirituality M - Medications I Incision in Care N - Nutrition E - Environment

F-Dar, Focus Charting - Document Transcript


1. DEFINITIONS: Focus Charting - is a method for organizing health information in the individual's record. It is a systematic approach to documentation, using nursing terminology to describe individual's health status and nursing action. Focus a key word or diagnostic category from a nursing diagnosis or collaborative problem on the plan of care (action plan), i.e. skin integrity, coping, activity tolerance, self care deficit a current individual concern or behavior, i.e. nausea, chest pain, pre-op teaching, hospital admission a sign or symptom of (possible) importance to the nursing and/or medical diagnosis or treatment plan, i.e. fever, constipation, hypertension, incontinence, lethargy an acute change in an individual's condition, i.e. respiratory distress, seizure, fever, discomfort a significant event in an individual's care, i.e. begin treatment regimen (oxygen), change in diet, catheterization a key word or phrase indicating compliance with a standard of care or agency policy, i.e. self medication teaching plan, transition COMPONENTS OF A FOCUS NOTE: 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. Example: Need: Comfort (or, Relief of pain) D - Complaining of continuous, sharp pain in mid-abdominal incisional area. Crying. "I need something for pain now!" States pain is 9 on a scale of 10. A - Medicated with Demerol 75mg IM in LUOQ of left buttock. Repositioned on right side with pillow to abdomen to help splint wound. R - Patient stated pain was "much better" 30 minutes later and rated it 3 on a scale of 10.---N. Nurse General Survey Appearance of the patient, condition- when seeing the patient Any IVF or Medications attaches to the arms of the patient Current Vital Signs of the Patient Eg. Approached sitting on bed, awake, responsive, coherent with ease in respiration, with O2 at 2 LPM, with an IVF of 4 PLR 1L + 8.25 meq KCl @ 2. 66 ugtts/min infusing well at the Right arm, with the following V/S: BP= 110/70 mmHG, PR= 100 bpm, RR= 26 cpm, T= 36.8 degree Celsius/axilla. Followed by F-DAR After writing the F-DAR , at the end of the shift write again your general observation/survey of the patient condition F: Hyperthermia D: > increase in body temperature above normal range to T= 38 degree Celsius/axilla > flushed skin and warm to touched A: 9:00am > Tepid sponge bath done > instructed SO to let patient wear loose clothing > instructed SO to provide blanket to patient when shiver > instructed SO to let patient drink lots of fluid > instructed SO to include in his diet foods rich in Vitamin C such as oranges > provided opportunity for patient to rest > due meds given R: 1:00pm > patient was able to rest > patient temperature decrease to T= 37.8 degree Celsius/axilla 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= 37.7 degree celsius/axilla F3: Fatigue D1: less movement noted with the verbalization of kapoy man ako lawas, kulangan ko ug katulog 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) 3. 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 Discharge plan for patient who undergo Surgery H Health Teachings A Anticipatory Guidance S - Spirituality M - Medications I Incision in Care N Nutrition E - Environment

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: Action a nursing Response diagnosi s a sign or a sympto m an acute change in the conditio n

behavior

Examples Pain
The focus of this problem is pain. Notice the way the D,A,R were written. Date/Hour 5/20/2010 8:00pm Focus Pain Progress Notes 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 5/20/2010 8:00pm

Focus Hyperthermia D:

Progress Notes

>Temperature of 38.9 OC via axilla >Skin is flushed and warm to touch A: >Tepid Sponge Bath (TSB) done 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

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

Our hospital does focus/problem charting as well in the DARE format and our charting comes with a flowsheet of your initial assessment as well as any following assessments. If the shift is "uneventful" meaning, no significant change in VS or condition. I like to put in procedures pt. left the unit for and who was visited by the pt. ex. 1330 - A - pt transported via gourney to CT scan on 1L N/C. Pt. handoff communication form completed, no RN supervision necessary 1500 A- visited by Dr. Smith, aware of CT Chest and ABG results then toward the end of your shift I would jot down something related to the reason why the patient is in the hospital in the first place D- Dx of pneumonia, Hx COPD on 1L O2 via NC with sats between 92-94% throughout shift. BP 134/85 RR 19 Oral temp 97.6 , sinus rhythm on monitor R - denies pain, unchange in baseline status, appears in no distress, agrees with POC E - continue with POC Just know something ALWAYS happens, whether he is seen by Dr. so and so or the physical therapist, etc. I try not to double chart, however. Say the patient's got a Foley cath. I just check off the "FC" in our flowsheet along with the color and clarity. I do not have to go to the written part of our flowsheet and write pt with 16F F/C draining 950 cc since 0830 clear, yellow urine...unless there was a "problem" like he had clots which required irrigation, or the FC came out and a new one had to be re-inserted... my day is super busy. Charting a novel doesn't always guarantee clear, concise documentation as well as I have no time for it. Straightforward and to the point is the best way to go in a hospital who does problem of focus charting. Good luck, practice makes perfect

I would think you could put something like this: Focus- Pt's condition unchanged, no improvement, no declination Data- saO2 90%, RR 28, BP 100/60, T 98.6, HR 98 Action- no changes, continue to follow care plan Response- patient condition stable, resting comfortably.

I would think you could put something like this: Focus- Pt's condition unchanged, no improvement, no declination Data- saO2 90%, RR 28, BP 100/60, T 98.6, HR 98 Action- no changes, continue to follow care plan Response- patient condition stable, resting comfortably.

focus charting is data, action response. For example: Focus- Pt. c/o SOB Data- saO2 90%, RR 28, BP 100/60 Action- Elevated HOB to high fowlers, applied 2L o2 nasal cannula Response- SaO2 95%, RR20, pt. denies SOB, resting comfortably. I was just wondering what kind of note I would write in that format if there were no significant events during the shift.

Data-Document subjective and objective data that supports the focus. This category reflects the assessment phase of the nursing process. Action-Describe your interventions, such as medication, treatment, calls to the physician, and patient teaching. This category reflects the planning and implementation phases of the nursing process. Response-Record the patient's response to your interventions. This entry always includes a new time. You may add this line, which reflects the evaluation phase of the nursing process, in a later note if necessary. An example of a good Focus note might look like this: 5/22 0730--Alteration in comfort; burning on urination. D: Pt. reports passing urine frequently and in small amounts, c urgency and burning sensation during urination. Urine is cloudy and dark amber. A: Notified Dr. Roberts. UA and culture specimens collected, antibiotic therapy initiated. Instructed Pt. to increase fluid intake c water and cranbery juice. 1530 R: Pt. reports experiencing moderate relief from urgency and burning. I&O increased to 480 ml. Lungs clear. S. Jobs, RN__________

Record routine nursing tasks and assessment data on flow sheets and checklists. Be sure to document consistently so others can track the patient's problems and progress.

1.Hi there, I am hoping someone can tell me if this looks right for a DAR. I'm in my first
semester of nursing and I'm so confused and I have to do my first skin/respiratory assessment and DAR with nursing diagnosis write up and have no idea if it's close to right. We have to make up our own each assessment, skin and respiratory has to include a normal geriatric variation and a regular abnormal variation. Skin: D - "I broke my wrist when I feel down a flight of stairs." Hair: loss of pigment, oily. Blanching: WNL, wrinkles around oral cavity, eyes, acrochordons right, left arms, hands, letigines right, left hand, skin: dry, petichiae right/left ankle, reduced tugor, edema 2, casted wrist dry, warm A - Educate client about using emolient for dry skin, hydration, hair care for oiliness, sunscreen R - Continue to monitor casted wrist, monitor input/output, continue to monitor vitals Your on the right track... Cast impedes movement/circulation---include neurovascular assessment.

2. What about pain statements pre and post medication?


Response to pain mgmt, positioning, use of pillows to elevate extremity +decrease edema Teaching regarding pain managment, s+s compromised circulation to report, along with cast care D- received lying on her bed conscious and coherent - with skeletal traction @ left leg - with long arm posterior mold @ right arm - vital signs taken and recorded A- bedside care done - placed in a comfortable position - back kept dry DAT(diet as tolereted) - served and consumed share with fair appetite - health teachings imparted with emphasis on: a. importance of proper positioning to promote lung expansion b. importance of proper hygiene to promote sense of well being c. importance of eating nutritious foods - kept traction weights hanging freely - maintained alignment of extremeties R- kept well rested -endorsed with latest v/s

In the last 24 hrs urinary output has been diminishing. Pt has indicated that he feels as though he is not emptying his bladder despite needing to void more frequently. This AM his bladder was distended and he is unable to pass his urine. He is quite uncomfortable and anxious, and is requesting Tylenol ES tab i for relief of a frontal headache. He is continent and successfully emptied his bowels yesterday. His physician has just ordered a #12-10cc foley catheter to continuous drainage to be inserted immediately to relieve urinary retention. VS: 168/92-88-20 Temp -36C " Focus: Urinary retention Data: Pt feels they are not emptying bladder despite the need to void more frequently. Urinary output significantly declined in last 24 hrs. Last void 16 hrs ago. Action: Palpated bladder, distension noted and pt unable to pass urine. Foley inserted as ordered by Dr. smiley to relieve urinary retention. 12Fr 10 mL balloon to gravity. Response: Pt indicated no pain during insertion. Draining clear yellow urine. 1000 mL out Focus: Frontal headache Data: Pt is requesting pain medication for relief of a frontal headache that started approx 1 hour ago. Pt c/o being uncomfortable and anxious. Pain is rated at 6/10 on pain scale. VS: BP168/92 P88 R20 T36C Action: Notified Dr who advised Pt be given Tylenol ES tab i. Writer administered Tylenol ES tab i as directed to pt. Response: Reassessed pain. Now 1/10. Pt states "I feel so much better". Focus: Nausea related to anesthetic D: Pt. states she's nauseated. Vomited 100ml clear fluid at 2255 A: Given Compazine 1mg IV at 2300. R: Pt. reports no further nausea at 2335. No further vomiting. Focus: Risk for infection related to incision sites D: Incision site in front of left ear extending down and around the ear and into neck-approximately 6 inches in length--without dressing. Jackson-Pratt drain in left neck below ear secured in place with suture. A: Assess site and emptied drain. Taught patient S&S of infection. R: No swelling or bleeding; bluish discoloration below left ear noted. JP drained 20mL bloody drainage. Patient states understanding of teaching. Focus: Delayed surgical recovery D: Patient reported dizziness after trying to get OOB to use the bathroom. A: Assisted patient back in bed and with use of bedpan. Taught patient how to dangle legs and get OOB slowly. Also taught coughing and deep breathing exercises, turning in bed, and use of entiembolism stockings. R: Patient voided 200mL in bedpan. Did cough and deep breathing appropriately. Lungs clear bilaterally. Using antiembolism stockings. Focus: Acute pain related to surgical incision

D: Patient reports pain as 7/10 on 0 to 10 scale. A: Given morphine 1mg IV at 2335. R: Patient reports pain as 1/10 at 2355.