FDAR CHARTING

(Focus-Data-Action-Response)

28 y/o Sex: ________

Age: _______ F Pt. verbalized, “I’m in labor. Tell me what I’m supposed to do.”
CC: ___________________________________________________________________
Medical Diagnosis: _________________________________________________________________________________
G1PO; AOG @ 39 weeks; membranes ruptured; in labor

Date, Time, and FOCUS PROGRESS NOTES

Shift
D- Arrived in ER with ruptured membranes; verbalized
to attending nurse, “I’m in labor. Tell me what I’m
supposed to do.” First pregnancy, unintended but
wanted; separated from the baby’s father for 7
November 30, 2020 Risk for ineffective
7:30AM coping months; close female friend as SO; no relatives
7AM-11PM present; T: 37.4; P: 100 bpm; BP: 120/80 mmHg; R:
21 cpm ; O2 Sat: 98% -------------------------------GERALI

A-Assessed for the presence of defining

characteristics; assessed for signs and symptoms of
ineffective coping; observed causes of ineffective
coping (e.g. poor self-concept, lack of problem-solving
skills, lack of support, or recent change in life
situation; helped the client seek realistic goals and
identify personal skills and knowledge; used
empathetic communication and encouraged pt. to
verbalize fears, express emotions, and set goals, and
be informed of labor progress and fetal well- being;
assisted in identifying situations that the pt. does have
control over (e.g. positioning, pain control methods,
relaxation techniques); encouraged decision making
and participation in planning of care and scheduled
activities; encouraged the pt. to describe previous
stressors and the coping mechanisms used; referred
pt. for counseling as needed---------------------- GERALI

R- Goal Met: Exhibited signs of calm when asking

questions regarding labor progress as well as
compliance with protocol procedures; also expressed
her preferences during labor ---------------------------------
-------------------------------------------------------------GERALI

MGCG, SN

Patient SH / Room No. | 1

 FDAR CHARTING
(Focus-Data-Action-Response)

28 y/o Sex: ________

Age: _______ F Pt. verbalized, “I’m in labor. Tell me what I’m supposed to do.”
CC: ___________________________________________________________________
Medical Diagnosis: _________________________________________________________________________________
G1PO; AOG @ 39 weeks; membranes ruptured; in labor

Date, Time, and FOCUS PROGRESS NOTES

Shift
D- Received at DR with D5LR @20 gtts/min; vital
signs obtained- T: 37.4; P: 100 bpm; BP: 120/80
mmHg; R: 21 cpm; O2 Sat: 98%; ROM @ 4:00 AM,
an hour prior to admission; contractions: 2 in 10 in the
November 30, 2020 Risk for infection
7:30AM last 25sec; last meal: 8 hours prior to admission; has
7AM-11PM history of trichomoniasis----------------------------------------
------------------------------------------------------------ GERALI

A- Vital signs monitoring q30mins done; assessed

immunization status and history; monitored signs and
symptoms of infection such as redness, swelling,
increased pain, purulent discharges from rupture: (a)
change in color, consistency, and amount of vaginal
discharge, (b) urinary frequency; dysuria; cloudy; foul-
smelling urine, (c) monitored temperature, report
single temperature greater than 100.5 F; assessed the
presence of local infectious processes in the skin or
mucous membranes; assessed vaginal discharge for
odor; monitored WBC count; maintained strict asepsis
(e.g. catheter and IV site handling); executed proper
handwashing before having contact with the patient;
imparted these duties to the patient’s SO------------------
------------------------------------------------------------ GERALI

R- Goal Met: Remained free of infection as evidenced by

normal vital signs and absence of signs and symptoms of
infection------------------------------------------------------- GERALI

MGCG, SN

Patient SH / Room No. | 2

 FDAR CHARTING
(Focus-Data-Action-Response)

28 y/o Sex: ________

Age: _______ F Pt. verbalized, “I’m in labor. Tell me what I’m supposed to do.”
CC: ___________________________________________________________________
Medical Diagnosis: _________________________________________________________________________________
G1PO; AOG @ 39 weeks; membranes ruptured; in labor

Date, Time, and FOCUS PROGRESS NOTES

Shift
D- Received at DR with D5LR @20 gtts/min; T:
37.4,P: 100 bpm; BP: 120/80 mmHg; R: 21 cpm; O2
Sat: 98%; Urine output: 150mL, 200mL--------------------
November 30, 2020 Risk for fluid ------------------------------------------------------------ GERALI
7:30AM volume deficit
7AM-11PM
A-Assessed and recorded: IV fluids and condition of
IV site every hour and RR, HR, BP and T every 4hrs
and PRN signs/symptoms of deficient fluid volume
every 4 hours and PRN; assessed and documented
the onset, intensity, character, location, duration,
aggravating factors, and relieving factors; assessed
skin turgor and oral mucous membranes for signs of
dehydration--------------------------------------------------------
------------------------------------------------------------ GERALI

R-Goal Met: Demonstrated adequate fluid volume as

evidenced by normal vital signs with oxygen
saturation between 95% -100% , temperature range of
36.5*C to 37.2*C, heart rate within 100 bpm, urine
output higher than 30 mL, and displayed negative
signs and symptoms of dehydration-------------------------
------------------------------------------------------------ GERALI

MGCG, SN

Patient SH / Room No. | 3

 FDAR CHARTING
(Focus-Data-Action-Response)

28 y/o Sex: ________

Age: _______ F Pt. verbalized, “I’m in labor. Tell me what I’m supposed to do.”
CC: ___________________________________________________________________
Medical Diagnosis: _________________________________________________________________________________
G1PO; AOG @ 39 weeks; membranes ruptured; in labor

Date, Time, and FOCUS PROGRESS NOTES

Shift
D- Arrived in ER with ruptured membranes; verbalized
to attending nurse, “I’m in labor. Tell me what I’m
supposed to do.” Attended preparation for labor
November 30, 2020 Health-seeking classes with a friend as coach; vital signs obtained- T:
7:30AM behaviors
7AM-11PM 37.4; P: 100 bpm; BP: 120/80 mmHg; R: 21 cpm;
O2 Sat: 98% -------------------------------------------GERALI

A-Assessed pt’s baseline knowledge; reiterated

information about procedures and normal progression
of labor; educated the client about breathing and
relaxation techniques appropriate to each phase of
labor; taught and reviewed pushing positions for stage
II-----------------------------------------------------------GERALI

R-Goal Met: Demonstrated appropriate breathing and

relaxation techniques, and participated in the duration
of the decision-making process concerning her
pregnancy---------------------------------------------- GERALI

MGCG, SN

Patient SH / Room No. | 4