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

FDARF- FOCUS D-DATA A-ACTION R-RESPONSE

LAST NAME: FIRST NAME: MIDDLE INITIAL: GENDER: AGE: ADMITTING PHYSICIAN:

DATE SHIFT TIME FOCUS D-DATA A-ACTION R-RESPOSE

FOCUS1) A current individual concerns or behavior. i.e. nausea, chest pain, headache2) A signs or symptoms of possible importance to the medical staff. i.e. fever, constipation, hypertension, incontinence, lethargy3) An acute change in an individual’s condition. i.e. respiratory distress, seizure, fever, discomfort.4) A significant event in an individual’s 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 plan6) 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 deficit7) Change of responsibility of patient care from one department to another. i.e. pre transfer assessment, post transfer assessment8) A significant treatment or intervention took place. i.e. hospital admission, discharge planning, pre-op teaching, pre or post (specify procedure) assessment

LAST NAME: FIRST NAME: MIDDLE INITIAL: GENDER: AGE: ADMITTING PHYSICIAN:

DATE SHIFT TIME FOCUS 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: FIRST NAME: MIDDLE INITIAL: GENDER: AGE: ADMITTING PHYSICIAN:

DATE SHIFT TIME FOCUS D-DATA A-ACTION R-RESPOSE

1/26/11 7-3 10:00AM

Chest Pain D: “Nag sakit akong dughan.” Midclavic line, c pain of 7 on scale of 10.-------- ---------------------Gino Carlo Acuram RN

10:05AM

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

12:00PM

R: Seen pt resting on bed in MHBR “ niarang arang na akong paminaw.”--------------------------------Gino Carlo Acuram RN

Focus charting must be evident at least once every shift.Always indicate the time ,date and shift of entry.

Consume spaces on the narrative notes as much as possible.

Draw line every empty spaces.

Place quotation mark on patient quotes.

Don't forget to put period and signature over printed name in every paragraph entry.

LAST NAME: FIRST NAME: MIDDLE INITIAL: GENDER: AGE: ADMITTING PHYSICIAN:

DATE SHIFT TIME FOCUS D-DATA A-ACTION R-RESPOSE

1/26/11

3-11 4:00PM

Risk for Infection r/t

D: Moderate amount of purulent, foul

lacerated wound 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 pt’s 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: FIRST NAME: MIDDLE INITIAL: GENDER: AGE: ADMITTING PHYSICIAN:

DATE SHIFT TIME FOCUS D-DATA A-ACTION R-RESPOSE 1/26/11

7-3 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 pt’s dry productive cough status. 1 sachet of fluimucil 600mg given P.O. as ordered.Instructed pt about the benefits of increasingOFI. ------------------------------------------------

-----------------------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

Hyperthermia D: Temperature of 38.3c , skin is flushed & warm to touch.------------------------------------

12:05PM

A: Teach & instruct pt’s watcher on proper way of performing TSB to pt. Paracetamol500mg/tab, 1tab given via PO as standing PRN order.-----------------------------------------

-----------------------Gino Carlo J. Acuram RN

2:30PM R: Temperature decrease from 38.3c to36.8c.---------------------------------------------------------------Gino Carlo J. Acuram RN

LAST NAME: FIRST NAME: MIDDLE INITIAL: GENDER: AGE: ADMITTING PHYSICIAN:

DATE SHIFT TIME FOCUS D-DATA A-ACTION R-RESPOSE

Nausea 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

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 callnurse when he is uncomfortable.-----------------------------------Gino Carlo J. Acuram RN

R: I understand the plan.--------------------------------------------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

LAST NAME: FIRST NAME: MIDDLE INITIAL: GENDER: AGE: ADMITTING PHYSICIAN:

DATE SHIFT TIME FOCUS D-DATA A-ACTION R-RESPOSE

Health Teaching: R: Patient demonstrates he is able to

Dressing Change 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: FIRST NAME: MIDDLE INITIAL: GENDER: AGE: ADMITTING PHYSICIAN:

DATE SHIFT TIME FOCUS D-DATA A-ACTION R-RESPOSE

LAST NAME: FIRST NAME: MIDDLE INITIAL: GENDER: AGE: ADMITTING PHYSICIAN:

DATE SHIFT TIME FOCUS 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.

UPDATEDFLOW SHEET

FLEXIBLECHECKLIST

QUALITY AND RELIABLE

FDAR DOCUMENTATION

FDAR SYSTEM

LAST NAME: FIRST NAME: MIDDLE INITIAL: GENDER: AGE: ADMITTING PHYSICIAN:

DATE SHIFT TIME FOCUS D-DATA A-ACTION R-RESPOSE 1/26/11

7-3 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 pt’s dry productive cough status. 1 sachet of fluimucil 600mg given P.O. as ordered.Instructed pt about the benefits of increasingOFI. ------------------------------------------------

-----------------------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

Hyperthermia D: Temperature of 38.3c , skin is flushed & warm to touch.------------------------------------

12:05PM

A: Teach & instruct pt’s watcher on proper way of performing TSB to pt. Paracetamol500mg/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.

DATESTARTED

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

INFUSION SHEET

FDAR DOCUMENTATION DO’s and DONT’s

DO’s1. 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.

DONT’s1. Don't begin charting until you check the name

and indentifying number on the patient chart on each page.

2. Don’t 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 physician’s 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