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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 individuals 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 Focus Progress Notes

3/7/20108:00pm Focus of care, DataActionResponse


this may be:
a
nursing
diagnosis
a sign
or a
symptom
an
acute
change in
the
condition
behavi
or

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 clients 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
irritableA:>Administered Celecoxib
200mg IV

>Encouraged deep
breathingexercises 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)
done7:30pm>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

Medical Terminologies & Abbreviations


List/Cheat Sheet
aa Of each, equal parts
ABR Absolute bed rest
Abd. Abdomen
ac Before meals
AD Admitting diagnosis
A&D Admission and discharge
Ad lib As desired, if the patient so desired
ADL Activities of daily living
Adm. Admission
Ad. Spec. Admission urine specimen
A.M. or a.m., AM or am Morning
amb Ambulation, walking, ambulatory,
able to walk
amt. Amount
AP or A.P. Appendectomy
aqua Water or H2O
@ At
Approx. Approximately
B&B or b&b Bowel and bladder training
bid or B.I.D. or b.i.d. Twice a day
b.m. or B.M. Bowel movement, feces
B.P. or BP Blood pressure
BR or br or B.R. or b.r. Bedrest
BRP or B.R.P. or brp Bathroom priviledges
BSC or bsc Bedside commode
C Celsius degree (or centigrade)
? With
Ca Cancer
Cath. Catheter
CBC or C.B.C. Complete blood count
cc or c.c Cubic centimeter
CCU or C.C.U Cardiac care unit/ coronary care unit
CBR or C.B.R. or cbr Complete bed rest
C/O or c/o Complaint of
CO2 Carbon dioxide
CS or C.S. or c.s Central supply
CSD or csd or C.S.D Central service department
CSR or csr and C.S.R Central supply room
CVA or C.V.A Cerebrovascular accident or stroke
CPR or C.P.R Cardiopulmonary resuscitation
dc or d/c Discontinue
del. M. Or d.r., or DR Delivery room
Disch or dish or D/C Discharge
D. % C. or D&C Dilatation and curettage
drsg. Dressing
DOA or D.O.A Dead on arrival
Dr. or Dr Doctor
DX Diagnosis
ECG or EKG Electrocardiogram
ED or E.D. Emergency department
EEG or E.E.G. Electroencephalogram
EENT or E.E.N.T. Eye, ears, nose and throat
E. or E Enema
ER or E.R. Emergency room
F Fahrenheit degree
F. or Fe. or F or Fe Female
FBS or F.B.S Fasting blood sugar
FF or F.F. Forced feeding or forced fluids
ft Foot
Fx Fracture
Fx urine Fractional urine
gal Gallon
GI or G.I. Gastrointestinal
gt One drop
gtt Two or more drops
Gtt or G.T.T. Glucose tolerance test
GU or G.U Genitourinary
Gyn. or G.Y.N. Gynecology
H2O Water or aqua
HOB Head of bed
hr Hour
HS or hs Bedtime or hour of sleep
ht Height
hyper Above or high
hypo Below or low
H.W.B. or hwb or HWB Hot water bottle
ICU or I.C.U. Intensive care unit
I&O or I.&O. Intake and output
Irr Irregular
Isol. Or isol Isolation
IV or I.V. Intravenous
L Liter
Lab. or lab Laboratory
lb Pound
LVN or L.V.N Licensed vocational nurse
M Male
Mat Maternity
MD or M.D. Medical doctor
Meas Measure
mec Meconium
med Medicine
min Minute
ml Milliliter
Mn or mn or M/n Midnight
N.A. or N/A Nursing aide or nursing assistant
n/g tube or ng. tube or N.G.T. Nasogastric tube
noct At night
NP Neuropsychiatric or nursing procedure
NPO or N.P.O Nothing by mouth
nsy Nursery
O2 Oxygen
OB or O.B. Obstetrics
Obt or obt. Obtained
OJ or O.J. Orange juice
Orb. Orderly
OOB or O.O.B. Out of bed
OPD or O.P.D. Outpatient department
OR or O.R. Operating room
Ortho Orthopedics
OT or O.T Occupational therapy or oral temperature
oz. Ounce
PAR or P.A.R. Postanesthesia room
Pc After meals
Ped or Peds Pediatrics
Per by, through
p.m. or P.M., pm or PM Afternoon
PMC or P.M.C Postmortem care
PN or P.N. Pneumonia
po By mouth
post or p after
postop or post op Postoperative
post op spec After surgery urine specimen
PP Postpartum (after delivery)
PPBS Postprandial blood sugar
pre Before
prn or p.r.n. Whenever necessary, when required
preop or pre op Before surgery
pre op spec Urine specimen before surgery
prep Prepare the patient for surgery by shaving the skin.
Pt or pt Patient; pint
PT or P.T. Physical therapy
q Every
qd Every day
qh Every hour
q2h Every 2 hours
q3h Every 3 hours
q4h Every 4 hours
QHS or qhs Every night at bed time/ hour of sleep
qid or Q.I.D. Four times a day
qam or q am or q.a.m. Every morning
qod or Q.O.D Every other day
qs Quantity sufficient, as much as required
qt quart
r or R rectal or Rectal
Rm or rm Room
RN or R.N. Registered nurse
Rom or R.O.M. Range of motion
RR or R Rm. Recovery room
Rx Prescription or treatment ordered by a physician
s or ? Without
S&A Sugar and acetone
S&A test or S.& A. test Sugar and acetone test
S&K or S.& K. test Sugar and ketone test
SOB Shortness of breath
sos Whenever emergency arises; only if necessary
SPD Special purchasing department
Spec or spec. Specimen
ss or ?? One-half
SSE or S.S.E. Soapsuds enema
Stat At once, immediately
STD Sexually transmitted disease
Surg Surgery
tid or T.I.D. Three times a day
TLC or tlc Tender loving care
TPR Temperature, pulse, respiration
TWE Tap water enema
U/a or U/A or u/a Urinalysis
Ung. Ointment, unguentine
VDRL Test for syphilis
V.S or VS Vital signs
WBC or W.B.C. White blood count
w/c Wheel chair
wc or W.C. Ward clerk
wt Weight

Medical/Nursing Abbreviations & Acronymns

For us health care workers, to effectively communicate either through oral communication and documentation, we
should be knowledgeable about the different abbreviations and acronyms.

The following is a short list of the different abbreviations and acronyms the health-care industry have:

A /G = albumin/globulin ratio
AAL = anterior Axillary Line
ABG = arterial blood gases
AC = before eating
ACE = angiotensin converting enzyme
ACL = Anterior Cruciate Ligament
ACLS = advanced cardiac life support
ACTH = adrenocorticotropic hormone
ADH = anti-diuretic hormone
ADL = activities of daily living
ADSF = Anterior Decomposition Spinal Fusion
AFB = acid-fast bacilli
AFP = alpha-fetoprotein
AGA = appropriate for gestational age
AGN = Acute Glomerulonephritis
AI = aortic insufficiency
AIDS = acquired immune deficiency syndrome
AKA = Above Knee Amputation
AKA = above knee amputation
ALD = alcoholic liver disease
ALL = acute lymphocytic leukemia
ALP = alkaline phosphatase
ALT = alanine transaminase, alanine aminotransferase
APR = Abdominoperineal Resection
ARF = Acute Renal Failure
ASA = Acute Surgical Abdomen
ATN = acute tubular necrosis
AU = both ears
AV = atrioventricular
ad lib = as much as needed

B.S. = Bachelor of Science


B/K = below knee
BAT = Blunt Abdominal Trauma
BIH = Bilateral Inguinal Hernia
BKA = Below Knee Amputation
BM = bowel movement or breast milk
BX = biopsy

c = with
C/O = complaining of
CA = calcium, cancer, carcinoma
CAA = crystalline amino acids
CABG = coronary artery bypass graft
CAD = coronary artery disease
CAPD = continuous ambulatory peritoneal dialysis
CAT = computerized axial tomography
CA = Cancer
CBC = complete blood count
CBD = common bile duct
CBDE = Common Bile Duct Exploration
CBD = Common Bile Duct
CBG = capillary blood gas
CBI = continuous bladder irrigation
CBS = capillary blood sugar
CC = chief complaint
CCK = cholecystokinin
CCPD = continuous cyclic peritoneal dialysis
CCU = clean catch urine or cardiac care unit
CCV = critical closing volume
CF = cystic fibrosis
CHF = congestive heart failure
CHO = carbohydrate
CI = cardiac index
CKD = Chronic Kidney Disease
CLEA = Continuous Lumbar Epidural Anesthesia
CLT = Clinical Laboratory Technician
CML = chronic myelogenous leukemia
CN = cranial nerves
CNS = central nervous system
CO = cardiac output
COM Chronic Otitis Media
COPD = chronic obstructive pulmonary disease
CP = chest pain, cleft palate
CPD = cephalo-pelvic disproportion
CPK = creatinine phosphokinase
CPP = cerebral perfusion pressure
CPR = cardiopulmonary resuscitation
CRCL = creatinine clearance
CRF = chronic renal failure
CRT = capillary refill time
CSF = cerebrospinal fluid
CT = computerized tomography
CVA = cerebral vascular accident, costovertebral angle
CVP = central venous pressure

D3 = Distal Third
D5W = 5% dextrose in water
DAT = diet as tolerated
DC = (dc) discontinue
DIC = disseminated intravascular coagulopathy
DIH = Direct Induinal Hernia
DKA = diabetic ketoacidosis
DL = Direct Laryngoscopy
DM = diabetes mellitus
DNA = deoxyribonucleic acid
DNR = do not resuscitate
DOA = dead on arrival
DOE = dyspnea on exertion
DPT = diphtheria, pertussis, tetanus
DTR = deep tendon reflexes
DVT = deep venous thrombosis
DX = diagnosis

EAA = essential amino acids


EBL = estimated blood loss
EBV = Epstein-Barr Virus
ECCE = Extra Capsular Cataract Extraction
ECF = extracellular fluid, extended care facility
ECG = electrocardiogram
ECT = electroconvulsive therapy
EDC= Extensor Digitorum Communis
EDH = Epidural Hematoma
EEA = End to end Anastomosis
EEL = Emergency Exploratory Laparotomy
EENT = eye, ear, nose and throat
EFAD = essential fatty acid deficiency
EGD = Esophagogastroduodenoscopy
EMG = electromyogram
EMV = eyes, motor, verbal response (Glasgow coma scale)
ENT = ears, nose, and throat
EOM = extraocular muscles
ERCP = Endoscopic Retrograde Cholangiopancreatography
ESR = erythrocyte sedimentation rate
ESRD = end stage renal disease
ET = endotracheal tube
ETT = endotracheal tube
EUA = examination under anesthesia

FBE = Foreign Body Extraction


FBS = fasting blood sugar
FCU = Flexor Carpi Ulnaris
FDA = Food & Drug Administration
FDP = Flexor Digitorum Profundus
FDS = Flexor Digitorum Superficial
FESS = Functional Endoscopic Sinus Surgery
FEV = forced expiratory volume
FFP = fresh frozen plasma
FIA = Fistula in Ano
FNP = Family Nurse Practitioner
FTSG = Full Thickness Skin Grafting

GB = gallbladder
GC = gonorrhea
GCS = Glascow Coma Scale
GERD = gastroesophageal reflux disease
GETA = General Endotracheal Anesthesia
GFR = glomerular filtration rate
GI = gastrointestinal
GSW = Gunshot Wound
GTT = glucose tolerance test
GU = genitourinary
HB = hemoglobin
HBP = high blood pressure
HCG = human chorionic gonadotropin
HCO3 = bicarbonate
HCT = hematocrit
HD = hemodialysis
HDL = high density lipoprotein
HEENT = head, eyes, ears, nose, throat
HPT = Hemoperitoneum

I & D = Incision & Drainage


IBG = Iliac Bone Graft
ICS = Intercostal Space
IIH = Indirect Inguinal Hernia
IJ = Intrajugular
IOC = Intraoperative Cholangiogram