FDAR Charting Sample

DATE AND TIME	FOCUS	DATA, ACTION, RESPONSE
12/30/14   8:00pm	Post-operative	D - S/P radical prostatectomy; with dressing over
	care	incision site on hypogastric area, dry & intact; with
		foley catheter attached to urometer, draining well;
		with Jackson Pratt, draining sanguineous fluid; total
		JP output for previous shift: 34cc; ongoing IVF of
		D5NR1L x 8hrs at right hand infusing well -----------kbv
8:10pm		A - Initial VS taken: 140/80mmHg, 83bpm, 21cpm,
		37.2'C------------------------------------------------------------kbv
8:15pm		A - Monitored JP output: 11cc--------------------------kbv
8:25pm		A - Monitored urine output every hour---------------kbv
8:30pm	Safety and	D - With complaints of minimal pain over incision
	comfort	site, graded 4/10; no grimace; tolerable -----------kbv
8:35pm		A - Encouraged deep breathing exercises ------- kbv
		A - Assisted to a comfortable position -------------- kbv
		A - Encouraged diversional activities --------------- kbv
8:45pm		A - Placed call light within reach ---------------------- kbv
		A - Instructed to call nurses station if in need of
		assistance ---------------------------------------------------- kbv
		A - Instructed to maintain the side rails up when in
		bed-------------------------------------------------------------- kbv
9:15pm	Cough	D - Complaints of dry cough, with increased pain
		on incision site during episodes 6/10 ----------------- kbv
		A - Instructed to use pillows as splint on incision site
		when coughing -------------------------------------------- kbv
		A - Lozenges taken, care of patient ----------------- kbv
9:50pm		R - Reassessed patient: states slight relief of throat,
		------ o v e r -------
		------ c o n t I n u e d -------
		decreased episodes of cough ----------------------- kbv
10:10pm	Inadequate	D - Urine output 45cc for this hour, dark yellow in
	urine output	color ------------------------------------------------------------ kbv
		A - Provided alternating warm&cold compress-kbv
		A - Dr. C informed through SMS ------------------------ kbv
10:20pm		A - Fast drip 200cc IVF ------------------------------------ kbv
11:00pm		A - Urine output for this hour: 38cc -------------------- kbv
		A - Dr. C informed ------------------------------------------ kbv
11:20pm		A - Fast drip 200cc IVF ------------------------------------ kbv
12/30/14 12:00am	Safety and	A – Seen patient resting comfortably --------------- kbv
	comfort	A – Provided adequate rest periods ----------------- kbv
		A – Provided environment conducive for sleep-- kbv
12:10am	Post-operative	A – Monitored JP drain: 9cc----------------------------- kbv
12:20am	care	A – Urine output: 45cc------------------------------------- kbv
		A – Furosemide(Lasix)20mg IV given as ordered- kbv
1:00am		R – Urine output: 58cc ------------------------------------ kbv
		R – Monitored for the further recurrence of output
		inadequacy ------------------------------------------------- kbv
1:45am		A - Seen patient asleep ---------------------------------- kbv
2:10am	Pain	A – Patient complaints of pain on IV site, graded
		6/10, swollen upon inspection ------------------------- kbv
2:15am		A – Placed warm compress on area for 15mins – kbv
2:30am		A – Reassessed patient, still with 6/10 pain --------- kbv
2:40am		A – Informed MROD through SMS --------------------- kbv
		A – Continued present management -------------- kbv
		------ o v e r -------
		------ c o n t I n u e d -------
3:10am		A – With increasing pain, graded 7/10 -------------- kbv
3:20am		A – Informed MROD --------------------------------------- kbv
4:00am		R – Changed IV site to left hand; with IVF infusing
		well; with no complaints of pain in new site; 3/10
		over previous site ------------------------------------------- kbv
4:15am		A - Drained JP: 8cc ---------------------------------------- kbv
5:00am	Post-operative	A – Seen patient, not in any distress, no subjective
	care	complaints --------------------------------------------------- kbv
5:40am		A – CBG taken: 118mg/dl ------------------------------- kbv
6:00am		R – With stable vital signs: 130/80mmHg, 80bpm,
		19cpm, 37.4'C; With dressing dry & intact; foley
		catheter draining well; total JP output for entire
		shift: 28cc, draining sanguineous fluid -------------- kbv
	Safety and	R – Patient comfortable, no untoward incident
	comfort	during entire shift ------------------------------------------- kbv
		kbvicente Kerstin Karen B. Vicente, RN Lic. No. 766245   R – Endorsed patient to -------, RN for continuity of
		care------------------------------------------------------------- kbv