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 individuals record. Focus Charting is a systematic approach to documentation. Three columns are usually used in Focus Charting for documentation:

Date and Hour; Focus and; Progress Notes.

The progress notes are organized into (D) data, (A) action, and (R) response, referred to as DAR (third column). Here is an example of a format of Focus Charting or F-DAR

Date/Hour 3/7/20108:00pm

Focus

Progress Notes

Focus of care, DataActionResponse this may be:

a
nursing diagnosis

a sign
or a symptom

an
acute change in the condition

behavi
or

The Data Category

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.

The Action Category

The action category reflects the planning and implementation phase of the nursing prosess and includes immediate and future nursing actions. It may also include any changes to the plan of care.

The Response Category

The response category reflects the evaluation phase of the nursing process and describes the clients response to any nursing and medical care.

Focus Charting Samples

Listed below are sample focus charting for different problems.

Pain
The focus of this problem is pain. Notice the way the D,A,R were written.

Date/Hour 5/20/20108:00pm Pain

Focus

Progress Notes D:>Reports of sharp pain on the abdominal incision area with a pain scale of 8 out of 10>Facial grimacing>Guarding behavior>Restless and irritableA:>Administered Celecoxib 200mg IV >Encouraged deep breathingexercises and relaxation techniques >Kept patient comfortable and safe R: >Patient reports pain was relieved

Hyperthermia
Date/Hour Focus Progress Notes D:>Temperature of 38.9 OC via axilla>Skin is flushed and warm to touchA:>Tepid Sponge Bath (TSB) done7:30pm>Administered 250mg IV Paracetamol as per doctors order>Encouraged adequate oral fluid intake

5/20/20108:00pm Hyperthermia

>Encouraged adequate rest R: 10:00pm>Temperature decreased from 38.9 to 37.1 OC

Another Variation
This is DAR made by Jay-D Man of Slideshare.net. with some modifications made. This is a very good variation. 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= 38.9 degree celsius/axilla F3: Fatigue D1: less movement noted A: 9:00am

9:30am

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 elevated the head of the bed (moderate high back rest) provided comfort measures and provide opportunity for patient to rest due meds given

 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

Medical Terminologies & Abbreviations List/Cheat Sheet

aa ABR Abd. ac AD A&D Ad lib ADL Adm. Ad. Spec. A.M. or a.m., AM or am amb amt. AP or A.P. aqua @ Approx. B&B or b&b bid or B.I.D. or b.i.d. b.m. or B.M. B.P. or BP BR or br or B.R. or b.r. BRP or B.R.P. or brp BSC or bsc Of each, equal parts Absolute bed rest Abdomen Before meals Admitting diagnosis Admission and discharge As desired, if the patient so desired Activities of daily living Admission Admission urine specimen Morning Ambulation, walking, ambulatory, able to walk Amount Appendectomy Water or H2O At Approximately Bowel and bladder training Twice a day Bowel movement, feces Blood pressure Bedrest Bathroom priviledges Bedside commode

C ? Ca Cath. CBC or C.B.C. cc or c.c CCU or C.C.U CBR or C.B.R. or cbr C/O or c/o CO2 CS or C.S. or c.s CSD or csd or C.S.D CSR or csr and C.S.R CVA or C.V.A CPR or C.P.R dc or d/c del. M. Or d.r., or DR Disch or dish or D/C D. % C. or D&C drsg. DOA or D.O.A Dr. or Dr DX ECG or EKG ED or E.D. EEG or E.E.G. EENT or E.E.N.T. E. or E ER or E.R. F F. or Fe. or F or Fe FBS or F.B.S FF or F.F. ft Fx Fx urine gal GI or G.I. gt gtt Gtt or G.T.T. GU or G.U Gyn. or G.Y.N. H2O HOB

Celsius degree (or centigrade) With Cancer Catheter Complete blood count Cubic centimeter Cardiac care unit/ coronary care unit Complete bed rest Complaint of Carbon dioxide Central supply Central service department Central supply room Cerebrovascular accident or stroke Cardiopulmonary resuscitation Discontinue Delivery room Discharge Dilatation and curettage Dressing Dead on arrival Doctor Diagnosis Electrocardiogram Emergency department Electroencephalogram Eye, ears, nose and throat Enema Emergency room Fahrenheit degree Female Fasting blood sugar Forced feeding or forced fluids Foot Fracture Fractional urine Gallon Gastrointestinal One drop Two or more drops Glucose tolerance test Genitourinary Gynecology Water or aqua Head of bed

hr HS or hs ht hyper hypo H.W.B. or hwb or HWB ICU or I.C.U. I&O or I.&O. Irr Isol. Or isol IV or I.V. L Lab. or lab lb LVN or L.V.N M Mat MD or M.D. Meas mec med min ml Mn or mn or M/n N.A. or N/A n/g tube or ng. tube or N.G.T. noct NP NPO or N.P.O nsy O2 OB or O.B. Obt or obt. OJ or O.J. Orb. OOB or O.O.B. OPD or O.P.D. OR or O.R. Ortho OT or O.T oz. PAR or P.A.R. Pc Ped or Peds Per

Hour Bedtime or hour of sleep Height Above or high Below or low Hot water bottle Intensive care unit Intake and output Irregular Isolation Intravenous Liter Laboratory Pound Licensed vocational nurse Male Maternity Medical doctor Measure Meconium Medicine Minute Milliliter Midnight Nursing aide or nursing assistant Nasogastric tube At night Neuropsychiatric or nursing procedure Nothing by mouth Nursery Oxygen Obstetrics Obtained Orange juice Orderly Out of bed Outpatient department Operating room Orthopedics Occupational therapy or oral temperature Ounce Postanesthesia room After meals Pediatrics by, through

p.m. or P.M., pm or PM PMC or P.M.C PN or P.N. po post or p postop or post op post op spec PP PPBS pre prn or p.r.n. preop or pre op pre op spec prep Pt or pt PT or P.T. q qd qh q2h q3h q4h QHS or qhs qid or Q.I.D. qam or q am or q.a.m. qod or Q.O.D qs qt r or R Rm or rm RN or R.N. Rom or R.O.M. RR or R Rm. Rx s or ? S&A S&A test or S.& A. test S&K or S.& K. test SOB sos SPD Spec or spec. ss or ?? SSE or S.S.E. Stat

Afternoon Postmortem care Pneumonia By mouth after Postoperative After surgery urine specimen Postpartum (after delivery) Postprandial blood sugar Before Whenever necessary, when required Before surgery Urine specimen before surgery Prepare the patient for surgery by shaving the skin. Patient; pint Physical therapy Every Every day Every hour Every 2 hours Every 3 hours Every 4 hours Every night at bed time/ hour of sleep Four times a day Every morning Every other day Quantity sufficient, as much as required quart rectal or Rectal Room Registered nurse Range of motion Recovery room Prescription or treatment ordered by a physician Without Sugar and acetone Sugar and acetone test Sugar and ketone test Shortness of breath Whenever emergency arises; only if necessary Special purchasing department Specimen One-half Soapsuds enema At once, immediately

STD Surg tid or T.I.D. TLC or tlc TPR TWE U/a or U/A or u/a Ung. VDRL V.S or VS WBC or W.B.C. w/c wc or W.C. wt

Sexually transmitted disease Surgery Three times a day Tender loving care Temperature, pulse, respiration Tap water enema Urinalysis Ointment, unguentine Test for syphilis Vital signs White blood count Wheel chair Ward clerk Weight

Medical/Nursing Abbreviations & Acronymns

For us health care workers, to effectively communicate either through oral communication and documentation, we should be knowledgeable about the different abbreviations and acronyms. The following is a short list of the different abbreviations and acronyms the health-care industry have: A /G = albumin/globulin ratio AAL = anterior Axillary Line ABG = arterial blood gases AC = before eating ACE = angiotensin converting enzyme ACL = Anterior Cruciate Ligament ACLS = advanced cardiac life support ACTH = adrenocorticotropic hormone ADH = anti-diuretic hormone ADL = activities of daily living ADSF = Anterior Decomposition Spinal Fusion AFB = acid-fast bacilli AFP = alpha-fetoprotein AGA = appropriate for gestational age AGN = Acute Glomerulonephritis AI = aortic insufficiency AIDS = acquired immune deficiency syndrome AKA = Above Knee Amputation AKA = above knee amputation ALD = alcoholic liver disease

ALL = acute lymphocytic leukemia ALP = alkaline phosphatase ALT = alanine transaminase, alanine aminotransferase APR = Abdominoperineal Resection ARF = Acute Renal Failure ASA = Acute Surgical Abdomen ATN = acute tubular necrosis AU = both ears AV = atrioventricular ad lib = as much as needed B.S. = Bachelor of Science B/K = below knee BAT = Blunt Abdominal Trauma BIH = Bilateral Inguinal Hernia BKA = Below Knee Amputation BM = bowel movement or breast milk BX = biopsy c = with C/O = complaining of CA = calcium, cancer, carcinoma CAA = crystalline amino acids CABG = coronary artery bypass graft CAD = coronary artery disease CAPD = continuous ambulatory peritoneal dialysis CAT = computerized axial tomography CA = Cancer CBC = complete blood count CBD = common bile duct CBDE = Common Bile Duct Exploration CBD = Common Bile Duct CBG = capillary blood gas CBI = continuous bladder irrigation CBS = capillary blood sugar CC = chief complaint CCK = cholecystokinin CCPD = continuous cyclic peritoneal dialysis CCU = clean catch urine or cardiac care unit CCV = critical closing volume CF = cystic fibrosis CHF = congestive heart failure CHO = carbohydrate CI = cardiac index CKD = Chronic Kidney Disease

CLEA = Continuous Lumbar Epidural Anesthesia CLT = Clinical Laboratory Technician CML = chronic myelogenous leukemia CN = cranial nerves CNS = central nervous system CO = cardiac output COM Chronic Otitis Media COPD = chronic obstructive pulmonary disease CP = chest pain, cleft palate CPD = cephalo-pelvic disproportion CPK = creatinine phosphokinase CPP = cerebral perfusion pressure CPR = cardiopulmonary resuscitation CRCL = creatinine clearance CRF = chronic renal failure CRT = capillary refill time CSF = cerebrospinal fluid CT = computerized tomography CVA = cerebral vascular accident, costovertebral angle CVP = central venous pressure D3 = Distal Third D5W = 5% dextrose in water DAT = diet as tolerated DC = (dc) discontinue DIC = disseminated intravascular coagulopathy DIH = Direct Induinal Hernia DKA = diabetic ketoacidosis DL = Direct Laryngoscopy DM = diabetes mellitus DNA = deoxyribonucleic acid DNR = do not resuscitate DOA = dead on arrival DOE = dyspnea on exertion DPT = diphtheria, pertussis, tetanus DTR = deep tendon reflexes DVT = deep venous thrombosis DX = diagnosis EAA = essential amino acids EBL = estimated blood loss EBV = Epstein-Barr Virus ECCE = Extra Capsular Cataract Extraction ECF = extracellular fluid, extended care facility ECG = electrocardiogram

ECT = electroconvulsive therapy EDC= Extensor Digitorum Communis EDH = Epidural Hematoma EEA = End to end Anastomosis EEL = Emergency Exploratory Laparotomy EENT = eye, ear, nose and throat EFAD = essential fatty acid deficiency EGD = Esophagogastroduodenoscopy EMG = electromyogram EMV = eyes, motor, verbal response (Glasgow coma scale) ENT = ears, nose, and throat EOM = extraocular muscles ERCP = Endoscopic Retrograde Cholangiopancreatography ESR = erythrocyte sedimentation rate ESRD = end stage renal disease ET = endotracheal tube ETT = endotracheal tube EUA = examination under anesthesia FBE = Foreign Body Extraction FBS = fasting blood sugar FCU = Flexor Carpi Ulnaris FDA = Food & Drug Administration FDP = Flexor Digitorum Profundus FDS = Flexor Digitorum Superficial FESS = Functional Endoscopic Sinus Surgery FEV = forced expiratory volume FFP = fresh frozen plasma FIA = Fistula in Ano FNP = Family Nurse Practitioner FTSG = Full Thickness Skin Grafting GB = gallbladder GC = gonorrhea GCS = Glascow Coma Scale GERD = gastroesophageal reflux disease GETA = General Endotracheal Anesthesia GFR = glomerular filtration rate GI = gastrointestinal GSW = Gunshot Wound GTT = glucose tolerance test GU = genitourinary HB = hemoglobin HBP = high blood pressure

HCG = human chorionic gonadotropin HCO3 = bicarbonate HCT = hematocrit HD = hemodialysis HDL = high density lipoprotein HEENT = head, eyes, ears, nose, throat HPT = Hemoperitoneum I & D = Incision & Drainage IBG = Iliac Bone Graft ICS = Intercostal Space IIH = Indirect Inguinal Hernia IJ = Intrajugular IOC = Intraoperative Cholangiogram