FDAR Charting Sample

DATE AND TIME

FOCUS
12/30/14 8:00pm Post-operative
care

8:10pm

8:15pm
8:25pm
8:30pm Safety and
comfort
8:35pm

8:45pm

9:15pm Cough

DATA, ACTION, RESPONSE

D - S/P radical prostatectomy; with dressing
over
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
A - Initial VS taken: 140/80mmHg, 83bpm,
21cpm,
37.2'C-----------------------------------------------------------kbv
A - Monitored JP output: 11cc-------------------------kbv
A
Monitored
urine
output
every
hour---------------kbv
D - With complaints of minimal pain over
incision
site,
graded
4/10;
no
grimace;
tolerable -----------kbv
A
Encouraged
deep
breathing
exercises ------- kbv
A
Assisted
to
a
comfortable
position -------------- kbv
A
Encouraged
diversional
activities --------------- kbv
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
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

10:10pm Inadequate
urine output

10:20pm
11:00pm

11:20pm
12/30/14 12:00am Safety and
comfort

12:10am Post-operative
12:20am care

1:00am

1:45am
2:10am Pain

2:15am
2:30am
2:40am

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
D - Urine output 45cc for this hour, dark yellow
in
color ----------------------------------------------------------- kbv
A - Provided alternating warm&cold compresskbv
A
Dr.
C
informed
through
SMS ------------------------ kbv
A
Fast
drip
200cc
IVF ------------------------------------ kbv
A
Urine
output
for
this
hour:
38cc -------------------- kbv
A
Dr.
C
informed ------------------------------------------ kbv
A
Fast
drip
200cc
IVF ------------------------------------ kbv
A

Seen
patient
resting
comfortably --------------- kbv
A

Provided
adequate
rest
periods ----------------- kbv
A Provided environment conducive for
sleep-- kbv
A

Monitored
JP
drain:
9cc----------------------------- kbv
A

Urine
output:
45cc------------------------------------- kbv
A Furosemide(Lasix)20mg IV given as
ordered- kbv
R

Urine
output:
58cc ------------------------------------ kbv
R Monitored for the further recurrence of
output
inadequacy ------------------------------------------------kbv
A
Seen
patient
asleep ---------------------------------- kbv
A Patient complaints of pain on IV site, graded
6/10,
swollen
upon
inspection ------------------------- kbv
A Placed warm compress on area for
15mins kbv
A Reassessed patient, still with 6/10
pain --------- kbv
A

Informed
MROD
through
SMS --------------------- kbv
A

Continued
present

3:10am
3:20am
4:00am

4:15am
5:00am Post-operative
care
5:40am
6:00am

Safety and
comfort

management -------------- kbv

------ o v e r ------------ c o n t I n u e d ------A

With
increasing
pain,
graded
7/10 -------------- kbv
A

Informed
MROD --------------------------------------- kbv
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
A
Drained
JP:
8cc ---------------------------------------- kbv
A Seen patient, not in any distress, no
subjective
complaints -------------------------------------------------- kbv
A

CBG
taken:
118mg/dl ------------------------------- kbv
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
R Patient comfortable, no untoward incident
during
entire
shift ------------------------------------------- kbv
kbvicente
Kerstin Karen B. Vicente, RN
Lic. No. 766245
R Endorsed patient to -------, RN for continuity
of
care------------------------------------------------------------ kbv