Nursing Related Topics

Gino Carlo J. Acuram R.N.

OBJECTIVE:
Within 1hour of lecture discussion, the class will be able to: 1) Enhance their understanding in progress notes documentation using FDAR. 2) Critically analyze different format of FDAR charting. 3)Raise awareness measures to avoid criminal liability

How to Complete a Progress Notes Using

FDAR
F- FOCUS D-DATA A-ACTION R-RESPONSE

LAST NAME: GENDER: DATE SHIFT

FIRST NAME: AGE: TIME FOCUS

MIDDLE INITIAL: ADMITTING PHYSICIAN: D-DATA A-ACTION R-RESPOSE

FOCUS
1) A current individual concerns or behavior. i.e. nausea, chest pain, headache 2) A signs or symptoms of possible importance to the medical staff. i.e. fever, constipation, hypertension, incontinence, lethargy 3) An acute change in an individuals condition. i.e. respiratory distress, seizure, fever, discomfort. 4) A significant event in an individuals care. i.e. begin treatment regimen (oxygen), change in diet, catheterization. 5) A key word or phase indicating compliance with a standard of care or agency policy. i.e. self medication teaching plan 6) A key word or diagnostic category from a nursing diagnosis or collaborative problem on the plan of care. i.e. skin integrity, coping, activity tolerance, self care deficit 7) Change of responsibility of patient care from one department to another. i.e. pre transfer assessment, post transfer assessment 8) A significant treatment or intervention took place. i.e. hospital admission, discharge planning, pre-op teaching, pre or post (specify procedure) assessment

LAST NAME: GENDER: DATE SHIFT

FIRST NAME: AGE: TIME FOCUS

MIDDLE INITIAL: ADMITTING PHYSICIAN: D-DATA A-ACTION R-RESPOSE

Purpose of FDAR
1) To easily identify critical patient issue and concerns. 2) To improve time efficiency with documentation. 3) To improve concise entries that would not duplicate patient information already provided.

LAST NAME: GENDER: DATE SHIFT 1/26/11 7-3

FIRST NAME: AGE: TIME FOCUS 10:00AM Chest Pain

MIDDLE INITIAL: ADMITTING PHYSICIAN: D-DATA A-ACTION R-RESPOSE D: Nag sakit akong dughan. Midclavic line, c pain of 7 on scale of 10.----------------------------Gino Carlo Acuram RN

10:05AM 12:00PM

A: Medicated with Isordil 5mg. SL----------------------------Gino Carlo Acuram RN

R: Seen pt resting on bed in MHBR ni

arang arang na akong paminaw.-------------------------------Gino Carlo Acuram RN

Place quotation mark on patient quotes. Don't forget to put period and signature over printed name in every paragraph entry. Focus charting must be evident least once shift. Always Draw line indicate every the empty time spaces. ,dateat and shift of every entry. Consume spaces on the narrative notes as much as possible.

LAST NAME: GENDER: DATE SHIFT 1/26/11 3-11

FIRST NAME: AGE: TIME FOCUS 4:00PM Risk for Infection r/t lacerated wound

MIDDLE INITIAL: ADMITTING PHYSICIAN: D-DATA A-ACTION R-RESPOSE

D: Moderate amount of purulent, foul

smelling drainage from lacerated wound @ L leg noted. Suture line red and swollen & warm to touch.-----------------------------------------------------Gino Carlo J. Acuram RN

4:10PM

A: Dr. Stuart notified & informed of pts

lacerated wound status. Wound discharges sample taken for C&S & sent to laboratory. Wound cleansed with antibacterial solution. & dry dressing applied.---------------------------------------------Gino Carlo J. Acuram RN

4:30PM

R: Lacerated wound dry and intact, no

discharges noted. ---------------------------------------------------Gino Carlo J. Acuram RN

LAST NAME: GENDER: DATE SHIFT 1/26/11 7-3

FIRST NAME: MIDDLE INITIAL: AGE: ADMITTING PHYSICIAN: TIME FOCUS D-DATA A-ACTION R-RESPOSE 7:00AM Dry Productive Cough D: Gahi kaayo ang akong ubo nurse . Dry Productive cough noted.-----------------------------------------Gino Carlo J. Acuram RN 7:10AM A: Dr. Johnson notified & informed of pts dry productive cough status. 1 sachet of fluimucil 600mg given P.O. as ordered. Instructed pt about the benefits of increasing OFI. ----------------------------------------------------------------------Gino Carlo J. Acuram RN 11:00AM

R: Mas arang arang na akong paminaw

Karon productive cough still noted. -----------------------Gino Carlo J. Acuram RN

1/26/11

7-3

12:00PM 12:05PM

Hyperthermia

D: Temperature of 38.3c , skin is flushed &

warm to touch.------------------------------------

A: Teach & instruct pts watcher on proper

way of performing TSB to pt. Paracetamol 500mg/tab, 1tab given via PO as standing PRN order.---------------------------------------------------------------Gino Carlo J. Acuram RN

2:30PM

R: Temperature decrease from 38.3c to

36.8c.--------------------------------------------------------------Gino Carlo J. Acuram RN

LAST NAME: GENDER: DATE SHIFT

FIRST NAME: AGE: TIME FOCUS Nausea

MIDDLE INITIAL: ADMITTING PHYSICIAN: D-DATA A-ACTION R-RESPOSE

D: I

feel like my stomach is filling up with pressure again and I'm nauseted. Abdomen round and soft, gastrostomy bag at body level, rare bowel sounds.----------------------------------Gino Carlo J. Acuram RN

Action and Response are repeated without additional data to show the sequence of decision making based on evaluating patient response to the initial intervention

A: Gastrostomy bag lowered.--------------------------------------Gino Carlo J. Acuram RN

R: I feel

like better now approximately 200 cc golden fluid returned as much flatus ----------------------Gino Carlo J. Acuram RN

A:

Keep gastrostomy bag at body level. monitor abdominal flatus, monitor how bag is tolerated at body level. Document time and amount of drainage and discomfort. Patient is instructed to call nurse when he is uncomfortable.----------------------------------Gino Carlo J. Acuram RN

R: I understand the plan.-------------------------------------------Gino Carlo J. Acuram RN

LAST NAME: GENDER: DATE SHIFT

FIRST NAME: AGE: TIME FOCUS Health Teaching: Dressing Change

MIDDLE INITIAL: ADMITTING PHYSICIAN: D-DATA A-ACTION R-RESPOSE R: Patient demonstrates he is able to change his own abdominal dressing using aseptic technique. --------------------------------------Gino Carlo J. Acuram RN

Response is used alone to indicate a care of plan goal has been accomplished.

LAST NAME: GENDER: DATE SHIFT

FIRST NAME: AGE: TIME FOCUS

MIDDLE INITIAL: ADMITTING PHYSICIAN: D-DATA A-ACTION R-RESPOSE

LAST NAME: GENDER: DATE SHIFT

FIRST NAME: AGE: TIME FOCUS

MIDDLE INITIAL: ADMITTING PHYSICIAN: D-DATA A-ACTION R-RESPOSE

Advantage of FDAR Charting

1) Flexible and can be adapted to fit any clinical setting. 2) It centers on the nursing process. 3) Easy to find information on a particular problem. 4) Ensures adherence to JCAHO requirements. 5) Can be used to document many topics without being confined to those on the problem list.

Disadvantages
1) May require in depth training, especially for staff familiar with other system. 2) Requires you to use many flow sheets and checklist.

FDAR SYSTEM

UPDATED FLOW SHEET

FLEXIBLE CHECKLIST

QUALITY AND RELIABLE FDAR DOCUMENTATION

LAST NAME: GENDER: DATE SHIFT 1/26/11 7-3

FIRST NAME: MIDDLE INITIAL: AGE: ADMITTING PHYSICIAN: TIME FOCUS D-DATA A-ACTION R-RESPOSE 7:00AM Dry Productive Cough D: Gahi kaayo ang akong ubo nurse . Dry Productive cough noted.-----------------------------------------Gino Carlo J. Acuram RN 7:10AM A: Dr. Johnson notified & informed of pts dry productive cough status. 1 sachet of fluimucil 600mg given P.O. as ordered. Instructed pt about the benefits of increasing OFI. ----------------------------------------------------------------------Gino Carlo J. Acuram RN 11:00AM

R: Mas arang arang na akong paminaw

Karon productive cough still noted. -----------------------Gino Carlo J. Acuram RN

1/26/11

7-3

12:00PM 12:05PM

Hyperthermia

D: Temperature of 38.3c , skin is flushed &

warm to touch.------------------------------------

A: Teach & instruct pts watcher on proper

way of performing TSB to pt. Paracetamol 500mg/tab, 1tab given via PO as standing PRN order.---------------------------------------------------------------Gino Carlo J. Acuram RN

Checklist are powerful tool to standardize work process. Although their format and content may vary, simple steps to identify, check and verify what you have done or are about to do can determine whether you succeed or fail.

ICU Charting Example >Received pt c IVF D5W500cc bottle no. 1 @ KVO rate, infusing well @ L hand. c IVF of PNSS1L bottle no 2 @ 20gtts/min infusing well @ R hand. > c side drip of Isoket drip @ 20 gtts/min > c tracheotomy tube attached to mechanical ventilator c the ff setup; FiO2=40%, RR=33, I:E=1:3, SI=55, TV=40, sensitivity=-2, PS=10. On AC mode. > Attached to cardiac monitor & pulse oximeter. > c distal end kept close for feeding @ R nostril; patent & intact. > c Foley catheter attached to urobag, draining to amber yellow colored urine @ the level of 300cc. AND ect.

INFUSION SHEET

DATE STARTED

TIME STARTED

# OF INFUSION

SITE OF IV INSERTION/TYPE OF CANNULA/DOSE/RATE/ DRUG INCORPORATION PRESENT (IV FLUIDS/BLOOD PRODUCTS/CHEMO/TPN)

DATE TERMINATED

TIME TERMINATED

FULL SIGNATURE OF RN

Jan 8, 2011

8:10AM

#1

L metacarpal vein, Introcan Safety G. 22, D5NM 1L X 6 hours at 42 gtts/min

Jan 8, 2011

2:00PM

GINO CARLO J. ACURAM RN LIC NO. 0432997

FDAR DOCUMENTATION DOs and DONTs

DOs
1. Do read what other providers have written, before providing care and before charting. 2. Do time and date all entries. 3. Do use flow sheet/checklist. 4. Do chart as you make observation. 5. Do write your own observation and signs over printed name. Sign and initial every entry. 6. Do described patients behaviour. 7. Do use direct patient quotes when appropriate.

8. Draw a line through any empty space at the end of an entry or at the bottom of the page. 9. Do include clinically relevant information about a complication, error, misadventure, etc. How the situation was handle administratively does not belong in the medical record. 10.Do be factual and complete. Record exactly what happen to patient and care given. 11.Do draw a single line thru an error, mark this entry as MISTAKEN ENTRY and sign your name. 12. Do write legibly. 13. Do use only approved abbreviation.

DONTs
1. Don't begin charting until you check the name and indentifying number on the patient chart on each page. 2. Dont chart in advance. 3. Don't clutter notes with repetitive or frequently changing data already charted on the flow sheet or checklist. 4. Don't make or sign an entry for someone else. 5. Don't change an entry because someone tell you to do so. 6. Don't label a patient or show bias. Stick to the facts and chose your word carefully if a mishap occurs. Do not argue your case in the medical record. Defensive entries can damage the credibility of the entire record.

7. Don't criticize physicians judgement or recommendation. 8. Don't white out or erase an error. 9. Don't squeeze in a missed entry or leave space for someone else who forgot to chart. 10. Don't use meaning less words and phrases such as good day or no complaints.

Example of Confused Wording in Documentation

>received pt with IVF On. >eats poorly >patient confused >medicated >kept warm >needs attended to >kept safe >cared for >endorsed

Points to Consider to Avoid Criminal Liability

1) Be very familiar with the Philippine Nursing Law. 2) Beware of laws that affect nursing practice. 3) At the start of employment, get a copy of your job description, the agency rules, regulation and policies. 4) Upgrade your skills and competence. 5) Accept only such responsibility that is within scope of your employment and your job description. 6) Do not delegate your responsibility to others. 7) Determine whether your subordinates are competent in the work you are assigning them. 8) Develop good interpersonal relationship with your co-workers, whether they be your supervisor, peers or subordinates. 9) Consult your superior for problems that may be too big for you to handle. 10) Verify orders that are not clear to you or those that seems to be erroneous. 11) The doctors should be informed about the patients condition. 12) Keep in mind and necessity of keeping accurate and adequate records. 13) Patient are entitled to an informed consent.

Thank You