F-Dar, Focus Charting

F-Dar, Focus Charting

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

2. 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.

3. 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

4. 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 @ 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. 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