Fdar

Definition
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

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).

Date/Hour Focus Progress Notes
3/7/2010
8:00pm
Focus of
care, this
may be:
a nursing
diagnosis
a sign or a
symptom
an acute
change in
the
condition
behavior
•Data
•Action
•Response

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.

Progress Notes
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.

Progress Notes
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.

Date/Hou
r
Focus Progress Notes
5/20/201
08:00am
10:00am
Pain D: Reports of sharp pain on the
abdominal incision area with a pain scale
of 8 out of 10. +Facial grimacing and
guarding behavior. The patient is restless
and irritable
A: Administered Celecoxib 200mg IV.
Encouraged deep breathing exercises and
relaxation techniques
R: Patient reports pain was relieved
Signature
Name
F-DAR for
Pain

Date/Hou
r
5/20/201
0
8:00pm
10:00pm
Hyperthermia D: Temperature of 38.9 OC via axilla.
Skin is flushed and warm to touch
A: Tepid Sponge Bath (TSB) done.
Administered 500mg IV Paracetamol prn
for fever as per doctor’s order.
Encouraged adequate oral fluid intake.
Encouraged adequate rest.
R: Temperature decreased from 38.9 to
37.1 OC
Signature
Name
F-DAR for
Hyperthermia

5/21/201
5
8:00am
3:00pm
Risk for
infection
D: With 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: Assessed sites for signs of infection,
emptied Jackson Prat drain and maintained
on negative pressure, instructed patient not
to touch the incision sites, taught signs and
symptoms of infection.
R: No swelling or bleeding; bluish
discoloration left ear noted. JP drained 20
mL bloody drainage, patient states
understanding of teaching given.
Signature
Name
F-DAR for
Risk for
infection

Date/Hou
r
4/20/202
1
8:00am
6:00pm
Edema D: Swelling of upper extremities noted, non-
pitting, latest albumin level of 1.98 g/dl dated
August 3, 2015
A: Monitored intake and output strictly,
intravenous fluid regulated at 40cc/hr; followed-
up requested 50 cc Human Albumin 20%,
monitored for signs and symptoms of pulmonary
congestion and progression of edema, added
Prosure and egg whites to feeding as ordered.
R: Still with swelling of upper extremities noted,
clear breath sounds noted upon auscultation, with
no signs of pulmonary congestion.
Signature
Name
F-DAR for
Edema

4/10/2021
8:00pm
6:00am
Nausea D: “I feel like my stomach is filling up with
pressure again and I’m nauseated”, abdomen
round and soft, gastrostomy bag at body level,
rare bowel sounds noted.
A: Keep gastrostomy bag lower than body
level, abdominal status monitored closely,
documented time, amount of drainage and
discomfort, instructed to report for recurrence
of nausea and abdominal discomfort.
R: “I feel better now”, approximately 200 cc of
golden watery feces removed and flatus noted.
Signature
Name
F-DAR for
Nausea

Date/Hou
r
1/2/2021
8:00am
6:00pm
Chest Pain D: “Gasakit ang dughan ko” with complaints chest
pain graded as 8 in a scale of 10, radiating to jaw
and relieved by rest as claimed, with BP of 90/60
mmHg, cardiac rate of 106 beats/min, synchronous
with pulse rate.
A: Instructed to maintain on complete bed rest, Dr.
Ruiz, MROD, informed, Isordil 5 mg SL given,
started oxygen at 2 liters /min via nasal cannula,
stat ECG taken, Troponin I taken, attached to
cardiac monitor, instructed to report progression of
chest pain.
R: Severity of pain decreased to 5/10 as claimed,
resting comfortably in bed, ECG revealed ST
elevation MI, with troponin result of 3.
Signature
Name
F-DAR for
Chest Pain

Date/Hou
r
1/6/202
1
9:00am
9:30am
Decreased level
of
consciousness
Unresponsivene
ss
D: GCS 3, no eye opening, no verbal output, and
no motor response, anisocoric pupils, with
temperature of 39oC
A: Monitored neurologic status and vital signs
closely, Dr. Cruz, MROD was notified, head of the
bed at 30 degrees elevation, body maintained on
neutral position, continuous ice bath performed,
due dose of Mannitol 175 cc IV bolus given, will
closely monitor for further deterioration of
neurologic status.
D: Pulse and BP unappreciated, no spontaneous
breathing with oxygen saturation of 89%; fixed
dilated pupils of 8mm; ventricular fibrillation
noted on the monitor.
A: High quality CPR done, Dr. Cruz, MROD seen
and examined the patient, significant others were
appraised of patient’s condition; ventilation via
bag mask at 10 liters/mi given, defibrillation at 36
joules done by Dr. Cruz, MROD, Epinephrine 1 mg
given with 3 minutes interval for 3 doses, flushed
with 20 cc normal saline and arm raised
thereafter, monitored for return of spontaneous

Date/Hou
r
9:45am Asystole
-continuation-
D: Flat line tracing on the monitor, pulse
unappreciated, patient’s family opted to stop
resuscitative measures
A: Waiver for DNR and refusal for emergency
medications secured and signed by patient’s wife,
rhythm strip taken, pronounced clinically dead by
Dr. Cruz, MROD, post mortem care done; brought
to morgue via canvass by Mr. Jose Fernandez
(Orderly on duty)
Signature
Name

Avoid phrases like:
• “Monitored for any untoward signs
and symptoms”
• “Referred accordingly”
• “Made comfortable in bed”
• “Due meds given”
• “Provided calm and restful
environment”

Fdar

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