Fdarcharting 120314214902 Phpapp02

SAMPLE DAR CHARTING
Date/Time Focus Nurse's Notes

31/5/2010 pre-operative care
F >Received asleep lying on bed with ongoing 5thIVF of PLRS iL+1 amp vit.b and vit.C x 16hoursat
150 cc level infusing well at the rightcephalic vein.
D>With intact and patent CTT at 5th left intercostalspace connected to thorabottle draining toyellowish
secretion. No signs of respiratorydistress. No compliants as of this moment.
A>Established rapport. Assessed for signs andsymptoms of respiratory

distress.Checked presence of dentures,nail polish, and jewelries.Dentures removed and handed
towatcher.Consent signed for Cholecystectomyattached to chart.Instructed on NPO.Oral
caredone. Shaving done. Skin prep done andclothing changed to O.R gown.Advised to dodeep
breathing exercises.Encouraged toverbalize feelings and concerns to upcoming procedure.
1:00 a.m >Above IVF consumed and replaced withthe 6thIVF of D5LRS 1L regulated to 28gtts/min.
R>Pt. was able to show readiness to upcomingoperation.Endorsed with an ongoing 6th IVF of D5LRS
iL x 28 gtts/min at 650 cc level andscheduled for cholecystectomy at 8 a.m

31/5/2010 Focus:mild pain
>Received lying on bed with ongoing 1st IVF of PNSS iL+2 amps.vit B and vit.C x 16 at 360cclevel
infusing well at left metacarpal vein.
D>With O2 inhalation at 2-4 LPM via nasalcannula.Poor skin nturgor noted. "nasakit ti takebko karkaru
nu agkutikuti ak" as verbalized. Pain israted as 4/10 and is localized on the anterior chest.Characterized
as pricking pain.Facial grimaces andguarding behaviors noted when in pain.
A>Established rapport. Assessed pain level andcharacteristic.Assessed skin turgor. Cutaneous

stimulation done. Provided quiet and calm environment.Positioned to comfort.
Encouragedverbalization of feelings.
5:20pm >above IVF consumed and 2nd IVF of PNSS il x16 hours replaced.
R>Pt. verbalized that pain is reduced from 4/10to 2/10.
11:00pm >Endorsed with ongoing 2nd IVF of PNSS iLx16at 800 cc level
5/31/2010Focus:elevated body >Received awake in a semi-fowler's position
7:00 am temperature with ongoing IVF of D5NSS il x8 at 950 cclevel infusing well at right cephalic vein arm.
D>with intact and patent IFC connected tourine bag draining to light yellow urine.
>"napudot ti riknak"as verbalized.With bodytemperature of 38.2oC per axilla.Withflushed face and

skin warm to touch.
A>Assessed patency of IFC.Assessed for signs of fever.TSB continuouslydone.Offered fluids

available at bedside.Removed extra clothings and blankets.Opened windows to enhance ventilation.
Emphasized importance of increasing fluidintake.Encouraged verbalization of feelingsand concerns.
2:30pm >Above IVF consumed and removed asordered.
R>Temperature lowered from 38.2oC to37oC
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 individual’s 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 Focus Progress Notes

3/7/20108:00pm Focus of care, this DataActionResponse
may be:
a nursing
diagnosis
a sign or a
symptom
an acute
change in
the
condition
behavior
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
client’s 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.

5/20/20108:00pm Pain 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 breathing

exercises and relaxation
techniques
>Kept patient comfortable

and safe
R:
>Patient reports pain was

relieved
Hyperthermia

5/20/20108:00pm Hyperthermia 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
doctor’s order>Encouraged
adequate oral fluid intake
>Encouraged adequate rest
R:
10:00pm>Temperature
decreased from 38.9 to 37.1
O
C
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
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
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

Fdarcharting 120314214902 Phpapp02

Uploaded by

Copyright:

Available Formats

Fdarcharting 120314214902 Phpapp02

Uploaded by

Document Information

Original Description:

Original Title

Copyright

Available Formats

Share this document

Share or Embed Document

Sharing Options

Did you find this document useful?

Is this content inappropriate?

Copyright:

Available Formats

Fdarcharting 120314214902 Phpapp02

Uploaded by

Copyright:

Available Formats

SAMPLE DAR CHARTING

Date/Time Focus Nurse's Notes

A>Established rapport. Assessed for signs andsymptoms of respiratory

Date/Time Focus Nurse's Notes

A>Established rapport. Assessed pain level andcharacteristic.Assessed skin turgor. Cutaneous

R>Pt. verbalized that pain is reduced from 4/10to 2/10.

>"napudot ti riknak"as verbalized.With bodytemperature of 38.2oC per axilla.Withflushed face and

A>Assessed patency of IFC.Assessed for signs of fever.TSB continuouslydone.Offered fluids

2:30pm >Above IVF consumed and removed asordered.

R>Temperature lowered from 38.2oC to37oC

Three columns are usually used in Focus Charting for documentation:

Date and Hour;

Here is an example of a format of Focus Charting or F-DAR

Date/Hour Focus Progress Notes

The Data Category

The Action Category

The Response Category

Focus Charting Samples

Listed below are sample focus charting for different problems.

Date/Hour Focus Progress Notes

>Encouraged deep breathing

>Kept patient comfortable

>Patient reports pain was

Date/Hour Focus Progress Notes

>Encouraged adequate rest

F1: Ineffective Breathing Pattern

D1: increase respiratory rate of 24 cpm

D2: use of accessory muscle to breath

D3: presence of nonproductive cough

D1: skin warm and flush to touched

D1: less movement noted

monitored v/s and charted

elevated the head of the bed (moderate high back rest)

tepid sponge bath done

F4: Discharge Plan (12:00nn)

D1: discharged order given by Dr.Name/Time

2:00pm – out of the room per wheelchair with improved condition

You might also like