Embracing changes: FDAR Charting

Bridgette sits in her usual seat in the auditorium as she listens to their orientation. Another semester has started and she is now one step closer to her dream of becoming a Registered Nurse. She listens intently as their Clinical Instructor briefs them on the things they need to observe in the Clinical setting and some changes that have happened in the last few weeks, including the style of documentation. No longer will they be writing on the nurse’s notes the traditional old way, instead another style of charting has been introduced.

FDAR charting. What is FDAR Charting? She has never even heard about that before and now they are about to use that when they go on duty. What is wrong with the old style? Why does it have to change? How do you do FDAR charting anyway? Frustrated, she fiddles with her white uniform as she listens more intently to what the announcer is speaking. Maybe it will shed some light on her queries and maybe she’ll be able to understand the importance of having to change some things.

 A closer look

Focus Data Action Response charting or FDAR charting, as it is more commonly called, describes the patient’s perspective and focuses more on documenting the patient’s current status, progress towards goals, as well as their response to interventions.

Furthermore, it is designed to easily identify critical patient issues/concerns in the Progress Notes, facilitate communication among all disciplines, improve time efficiency with documentation and provide brief entries that would not duplicate patient information already provided on flow sheet/checklist.

Certain situations call for this style of charting such as in describing a patient problem/ focus/ concern from the care plan, documenting an activity or treatment that was carried out, documenting new findings and an acute change in patient’s condition, identifying the discipline making the entry as well as the topic of the note and lastly, in describing all specifics regarding patient and/or family teaching. Also, it may be indicated when it comes to documenting a significant event or unusual episode in patient care, identifying an exemption to the expected outcome such as nausea, documenting an activity or treatment that the nurse and other members of the health team were not carried out, and in order to best describe patient’s condition in relation to medical diagnosis.

Like other styles of charting, there are also Do’s and Don’ts when it comes to FDAR charting, but ones of the most important to note are that the nurse must remember to put the date and time of documentation, sign the name at each entry, and to focus the charting and care on the patient instead of tasks (patient-oriented). Also, document only patient’s concern and/or plan of care such as when the nurse performs health teaching per shift, the patient’s status upon admission, for every transfer to/from another unit, or discharge. Specific pen colors may be used according to hospital policy.

Focus

– The nurse must identify the content or purpose of the narrative entry and they must be separated from the body of the notes. This is to promote easy data retrieval and communication.

Data

– The statements may contain objective and/or subjective information. Here, you may put your assessment such as the vital signs, other observations and the behaviors of the patient.

Action

– The planning and implementation phase, this is where nursing interventions come into the scenario, may it be basic, perspective, or independent; immediate or future nursing actions. It may also contain collaborative orders as well as any changes in the plans of care.

Response

– The evaluation phase, here you document evident patient outcomes or response. This is not added until later when the patient outcome is evident. It may also indicate whether the care of plan goal has been accomplished.

 

As the world moves around us, and some changes have began to emerge, certain steps must be taken in order to cope with these changes. Nursing isn’t an exception. In the pursuit of providing the best and quality health care as possible, nurses must be able to learn to adapt to changes and develop some ways in order to address it. Nurses must not only stick to what they already know, but try to be flexible and responsive for the sake of trying to meet the needs of the patients.

 

Sources:

Liane Clores, RN MAN

Currently an Intensive Care Unit nurse, pursuing a degree in Master of Arts in Nursing Major in Nursing Service Administration. Has been a contributor of Student Nurses Quarterly, Vox Populi, The Hillside Echo and the Voice of Nightingale publications. Other experience include: Medical-Surgical, Pediatric, Obstetric, Emergency and Recovery Room Nursing.

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