FDAR for Maternity

FDAR

A method for organizing health information in the individual’s record. It involves documenting focus, data, action, and response

Focus

Nursing problem, sign or symptom, patient behavior, acute change in the client’s condition, a significant event/upcoming procedure.

Example of nursing problem

Risk for bleeding, knowledge deficit

Example of sign or symptom

Fever, cough, pain

Example of patient behavior

Unable to ambulate, non-copmliance

Example of an acute change in the client’s condiiton

Loss of consciousness

Example of significant event/upcoming procedure

Surgery, for discharge

Data

Consciousness, complaints, contraptions, condition, vital signs, physical assessment, Doctor’s orders

Consciousness

State the level of consciousness

Examples of contraptions

IVF, o2 cannula, foley catheter, NGT

Example of vital signs

TPR+BP, pain level, O2 Sat

Example of physical assessment

cephalocaudal

Example of doctors orders

procedures and treatments that the client is about to undergo (urinalysis, stool exam, CBR without BRP, chest x-ray, ultrasound, surgical intervention)

Action

Verbs are always in past tense. include actions for monitoring, procedures done & education given

Response

Evaluation of care (document in reference to data received)