FDAR
Focus charting describes the patient’s
perspective and focuses on documenting the
patient’s current status, progress towards
goals and response to intervention.
Purpose
Focus charting bring the focus of care back to the
patient and the patients concerns. Instead of a problem
list or list of nursing and medical diagnosis, a focus
column is used that incorporates many aspects of
patient and patient care.
the focus might be patient strength, problem or need.
Topics that may appear in the focus column include
patients concerns and behaviors; therapies and
responses; significant events such as teaching,
consultation, monitoring, management of activities of
daily living or assessment of functional health patterns.
the narrative portion of focus charting includes
DATA, ACTION & RESPONSE (D A R). The
principal advantages of focus charting is in the
holistic emphasis on the patient and his/her
priorities including ease in charting.
Objectives
to easily identify critical patients issues/concerns in
the progress notes.
to facilitate communication among all disciples.
to improve time efficiency with documentation.
to improve concise entries that would not duplicate
patient information already provided on flowsheet /
checklist.
General Guidelines
Focus charting must be Evident at least one every shift.
Focus charting must be patient – oriented not nursing task – oriented.
Indicate the date and time of entry on the first column.
separate the topic words from the body of notes:
Focus note written on the second column.
Data, Action and Response on the third
column.
Sign name (e.g. RL Esperanza, MAN, RN) for every time
entry.
Document only patients concerns and or plan of care
e.g health per shift, hence, general notes are allowed.
Document patients status on the admission, for every
transfer to/from another unity of discharge.
Follow the do’s of documentation
Specific Guidelines
Begin with comprehensive assessment of the patient using
inspection, palpation, percussion, and auscultation (IPPA)
Include in the assessment, collection of information from
the patient, family, existing health records (such as checklist /
flow sheets, laboratory results and other health care
providers.
Established a focus of care, to be addressed in the Progress
Notes.
Document the four elements of focus Charting:
Focus identifies the content or purpose of the narrative entry and is
separated from the body of the notes in order to promote easy data
retrieval and communication.
Data is the subjective and/or objective information supporting the
stated focus or describing the observation at the time of significant
event,
Action describes the nursing intervention (independent, basic and
perspective) past, present or future.
Response describes the patient outcome/response to intervention or
describes how the care plan goals have been attained.
Focus Note
Example:
Self care Admission
Skin Integrity Pre-transfer assessment
Activity tolerance Discharge planning
Wheezes left base Transfusion RBC
Nausea Begin Thrombolytic Therapy
Respiratory Distress
Seizure
Code Blue
Data statements contain objective and/or subjective
information
Action statement contains only nursing interventions past,
present or future.
Patient outcome are evident in the response statements.
Data, Action, Response only contains information related to
the focus, none of the information is extraneous.
Response statement are documented after PRN medications
are administered.
DATA is used when the purpose of the note is to document assessment
finding and there is no flow sheet / checklist for that purpose.
ACTION & RESPONSE are repeated without additional data
to show the sequence of decision making based on evaluating
patient response to the initial intervention.
