FDAR CHARTING

Mary Lou Abraham

Remaining 8 weeks rotation

  • 1 sem = 18 weeks 9 weeks lecture 9 weeks duty

FDAR

  • Focuses

  • Data - cues

  • Action- planning interventions

  • Response- evaluation

Charting is your protection

  • And evidence

  • Honest the actual assessment and intervention

  • Ex. 10 patients equals 10 charting

What is FDAR

  • DEVELOPED by committee of staff nurses at EITEL hospital in Minneapolis Minnesota

  • Grew out of dissatisfaction of problem oriented progress notes

  • Patient centered

  • Document precisely and concisely

    • Answering the specific problem of the patient

    • So that we can asses the correct problem of the patient

    • Poor assessment= poor nursing care

    • SOP standard operating procedure

  • Necessary revisions

    • We can make many FDAR in 1 patient alone? Yes

    • Depends on the problem presented

    • Ex. Fever

      • Focus on the fever

      • After 2 hrs patient has LBM

      • You make another fdar

      • Kung Lima Lima man ang charting

      • Because we are answerjng each problem of our patient

  • OBJECTIVES

    • To easily identify critical patient issues and concern

      • In order to answer the needs of the patient

    • Facilitate communication among discipline

      • Team members upod monsa hospital nga ga read,

      • Chismis marites. Reality vs expectation mag duty kamo na idea ni: ms ang mga staff nurses npms tag 2 lang ka sentences, pero pag kita na bala sang mga doctor or chief nurses, ay kana,I gd ya sang CSAB Kay Damo info gn provide

      • You can communicate ay SI patient gali SI patient gn LBM gali sang 2 am

      • Failure to write the problem ma rekla moo so patient Kay Wala na chart

    • To improve the time efficiency with documentation

    • To provide concise entries that would not duplicated patient info that was already provided in the flow sheet

      • Information sheet/ admission sheet

      • Flow sheet for MiO, tpr

      • For medication

      • For IV fluid

      • For nurses notes

      • For laboratory Diagnosis spets

      • Ang vital signs Gina sulat na sa vital signs form

      • To win friends and influence people

      • We need to be concise cuz we are answering the needs the specific problem of our patient

    GENERAL GUIDELINES

    • ND KA KA PULE KONG ND MO MA TAPOS ANG NURSE SNOTES CUZ ITS YOU R RESPONSIBILITIES

    • MUST B patient oriented

      • More focus on a specific problem

      • Nurses notes doejd ion the institution

        • 3 coloumns

        • 4 coloumns

          • 1 column date - must be written in word not number - to avoid alteration

            • Tim

            • Sign name every entry

            • Document only oatei t concern and

      • Check body temp latest an hour

      • Documenustattus

  • WRONG CHARTING

    • REPORT IMMEDIATELY TO CI

    • GINA INFORM SI STAFF at the same time the headnurse

    • Write a line red color ball pencindrawdit and oerma and date

    • Not allowed to used signa ND gel pen

    • No super imposition

FOCUS

  • IDENTIFIES the content of the narrative entry

  • 2nd column

  • Witten problem itself or nursing dx

DATA

  • the subjective and/or objective information supporting the stated focus

  • If the problem is not relevant to the present problem write it on the other chart

What are the s/o database for stated focus

  • What is the patient telling you

  • What do you see hear touch or smell

  • What are the findinh indicate

  • Keep the cues of tey dat

ACTION

  • INCLUDE IMMEDITE INTERVENTIONS

  • WHAT AFTIONS DID THE CLINIC

RESPONSE

  • describe the patients response to any aspect of medical ie nursing care

  • Statement that the action of the plan of care outcomes have been attained or are progressing toward

  • Resolve, partially resorvle and unresolved - endorse on the incoming nurse.