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Sample Charting (Fdar)

The patient underwent various procedures and treatments during their hospital stay. Their vital signs were monitored, medications were administered, diagnostic tests were performed, and their condition was observed and addressed. The patient was discharged in stable condition accompanied by medical staff.

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Mary Beth Abelido
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935 views

Sample Charting (Fdar)

The patient underwent various procedures and treatments during their hospital stay. Their vital signs were monitored, medications were administered, diagnostic tests were performed, and their condition was observed and addressed. The patient was discharged in stable condition accompanied by medical staff.

Uploaded by

Mary Beth Abelido
Copyright
© © All Rights Reserved
Available Formats
Download as DOCX, PDF, TXT or read online on Scribd
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FOCUS Discharge Process

DATA Conscious and Coherent


No Complaints made
ACTION Summarized bills
IV pulled out aseptically
V/S monitored and recorded
Bill settled, Discharge slip secured
Patient home instruction instructed to folks
and verbalized understanding thereafter
All needs attended
RESPONSE Discharged per wheelchair accompanied by
the student nurse in stable condition.

FOCUS CBG Monitoring


DATA CBG result: 86mg/dl
ACTION Instructed to eat thereafter
Due meds given
RESPONSE Endorsed.

FOCUS Status
DATA (+) LBM or loose stool x2
(+) body weakness
(+) dry lips
VS:
ACTION Diaper changes noted for blood consistency
Bed pad changed
Fecalysis specimen sent
Oral medications given
IV antibiotic started after negative skin test.
RESPONSE No reaction from IV antibiotic

FOCUS Diagnostic Procedure


DATA For UTZ
ACTION Maintained on NPO
Brought to UTZ

RESPONSE UTZ done

FOCUS Altered Body Temperature


DATA Febrile at 38.7 degree Celsius
(+) chills
Warm to touch
ACTION Paracetamol ___mg ___ tab given
TSB instructed to folks
Encouraged increase fluid intake
Room Temperature regulated

RESPONSE

FOCUS IV Access
DATA IV cannula is dislodged
ACTION IVF pulled out aseptically
IVF reinsertion done at (time)
IVF regulated and infusing well
Made comfortable and all needs attended

RESPONSE Afebrile
VIP score = 0

FOCUS Discharge Process


DATA Conscious and Coherent
No Complaints made
ACTION Summarized bills
IV pulled out aseptically
V/S monitored and recorded
Bill settled, Discharge slip secured
Patient home instruction instructed to folks
and verbalized understanding thereafter
All needs attended
RESPONSE Discharged per wheelchair accompanied by
the student nurse in stable condition.

FOCUS Diagnostic Procedure


DATA For hepatobiliary ultrasound
On NPO status
ACTION Brought to ultrasound room per stretcher
accompanied by folks
Ultrasound procedure done by Dr. ______

Brought back to room per stretcher


Transferred to bed and made comfortable
RESPONSE Ultrasound findings relayed to attending
physician.

FOCUS Respiratory Status


DATA Received patient with IVF going on attached
to infusion pump
Afebrile
RR: ____ 02 Sat: _____ CR: ______
Oxygen tank standby on bedside
Occasional cough noted

ACTION Medications given orally


VS taken and recorded
Comfort measures provided
RESPONSE Ultrasound findings relayed to attending
physician.

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