Sunday, February 9, 2014

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


























































































































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