Focus Charting of F-DAR is intended to make the client and client concerns and strengths the focus of care. It is a

method of organizing health information in an individual’s record. Focus Charting is a systematic approach to

documentation.

Three columns are usually used in Focus Charting for documentation:

Date and Hour;

Focus and;

Progress Notes.

The progress notes are organized into (D) data, (A) action, and (R) response, referred to as DAR (third column).

Here is an example of a format of Focus Charting or F-DAR

Date/Hour Focus Progress Notes

3/7/20108:00pm Focus of care,

this may be:

a

nursing

diagnosis

a sign

or a

symptom

an

acute

change in

the

condition

behavi

or

DataActionResponse

The Data Category

The data category is like the assessment phase of the nursing process. It is in this category that you

would be writing your assessment cues like: vital signs, behaviors, and other observations noticed from

the patient. Both subjective and objective data are recorded in the data category.

The Action Category

The action category reflects the planning and implementation phase of the nursing prosess and includes immediate

and future nursing actions. It may also include any changes to the plan of care.

The Response Category

The response category reflects the evaluation phase of the nursing process and describes the client’s response to

any nursing and medical care.

Focus Charting Samples

Listed below are sample focus charting for different problems.

Pain

The focus of this problem is pain. Notice the way the D,A,R were written.

Date/Hour Focus Progress Notes

5/20/20108:00pm Pain D:>Reports of sharp pain on the

abdominal incision area with a pain

scale of 8 out of 10>Facial

grimacing>Guarding

behavior>Restless and

irritableA:>Administered Celecoxib

200mg IV

>Encouraged deep

breathingexercises and relaxation

techniques

>Kept patient comfortable and safe

R:

>Patient reports pain was relieved

Hyperthermia

Date/Hour Focus Progress Notes

5/20/20108:00pm Hyperthermia D:>Temperature of 38.9 OC via

axilla>Skin is flushed and warm to

touchA:>Tepid Sponge Bath (TSB)

done7:30pm>Administered 250mg

IV Paracetamol as per doctor’s

order>Encouraged adequate oral

fluid intake

>Encouraged adequate rest

R:

10:00pm>Temperature decreased

from 38.9 to 37.1 OC

Another Variation

This is DAR made by Jay-D Man of Slideshare.net. with some modifications made. This is a very good variation.

F1: Ineffective Breathing Pattern

D1: increase respiratory rate of 24 cpm

D2: use of accessory muscle to breath

D3: presence of nonproductive cough

F2: Hyperthermia

D1: skin warm and flush to touched

D2: increased body temperature of T= 38.9 degree celsius/axilla

F3: Fatigue

D1: less movement noted

A: 9:00am

monitored v/s and charted

regulated IVF and charted

morning care done

assessed patient needs and performed handwashing before handling the patient

advised SO to always stay on patient bedside

promote proper ventilation and a therapeutic environment

elevated the head of the bed (moderate high back rest)

provided comfort measures and provide opportunity for patient to rest

due meds given

9:30am

tepid sponge bath done

instructed SO to provide blanket and let patient wear loose clothing

F4: Discharge Plan (12:00nn)

D1: discharged order given by Dr.Name/Time

M – advised SO to give the ff. meds at the right time, dose, frequency and route

E – encouraged to maintain cleanliness of the house and surroundings

T – advised to go to follow-up consultations on the prescribed date

H – encouraged to do chest tapping to facilitate mobilization of secretion

O – observed for signs of super infections such as fever, black fury tongue and foul odor discharges

D – encouraged to eat fresh vegetables and fish

S – advised to continue praying to God and hear mass on Sunday

2:00pm – out of the room per wheelchair with improved condition

Medical Terminologies & Abbreviations List/Cheat Sheetaa Of each, equal parts

ABR Absolute bed rest

Abd. Abdomen

ac Before meals

AD Admitting diagnosis

A&D Admission and discharge

Ad lib As desired, if the patient so desired

ADL Activities of daily living

Adm. Admission

Ad. Spec. Admission urine specimen

A.M. or a.m., AM or am Morning

amb Ambulation, walking, ambulatory,

able to walk

amt. Amount

AP or A.P. Appendectomy

aqua Water or H2O

@ At

Approx. Approximately

B&B or b&b Bowel and bladder training

bid or B.I.D. or b.i.d. Twice a day

b.m. or B.M. Bowel movement, feces

B.P. or BP Blood pressure

BR or br or B.R. or b.r. Bedrest

BRP or B.R.P. or brp Bathroom priviledges

BSC or bsc Bedside commode

°C Celsius degree (or centigrade)

? With

Ca Cancer

Cath. Catheter

CBC or C.B.C. Complete blood count

cc or c.c Cubic centimeter

CCU or C.C.U Cardiac care unit/ coronary care unit

CBR or C.B.R. or cbr Complete bed rest

C/O or c/o Complaint of

CO2 Carbon dioxide

CS or C.S. or c.s Central supply

CSD or csd or C.S.D Central service department

CSR or csr and C.S.R Central supply room

CVA or C.V.A Cerebrovascular accident or stroke

CPR or C.P.R Cardiopulmonary resuscitation

dc or d/c Discontinue

del. M. Or d.r., or DR Delivery room

Disch or dish or D/C Discharge

D. % C. or D&C Dilatation and curettage

drsg. Dressing

DOA or D.O.A Dead on arrival

Dr. or Dr Doctor

DX Diagnosis

ECG or EKG Electrocardiogram

ED or E.D. Emergency department

EEG or E.E.G. Electroencephalogram

EENT or E.E.N.T. Eye, ears, nose and throat

E. or E Enema

ER or E.R. Emergency room

°F Fahrenheit degree

F. or Fe. or F or Fe Female

FBS or F.B.S Fasting blood sugar

FF or F.F. Forced feeding or forced fluids

ft Foot

Fx Fracture

Fx urine Fractional urine

gal Gallon

GI or G.I. Gastrointestinal

gt One drop

gtt Two or more drops

Gtt or G.T.T. Glucose tolerance test

GU or G.U Genitourinary

Gyn. or G.Y.N. Gynecology

H2O Water or aqua

HOB Head of bed

hr Hour

HS or hs Bedtime or hour of sleep

ht Height

hyper Above or high

hypo Below or low

H.W.B. or hwb or HWB Hot water bottle

ICU or I.C.U. Intensive care unit

I&O or I.&O. Intake and output

Irr Irregular

Isol. Or isol Isolation

IV or I.V. Intravenous

L Liter

Lab. or lab Laboratory

lb Pound

LVN or L.V.N Licensed vocational nurse

M Male

Mat Maternity

MD or M.D. Medical doctor

Meas Measure

mec Meconium

med Medicine

min Minute

ml Milliliter

Mn or mn or M/n Midnight

N.A. or N/A Nursing aide or nursing assistant

n/g tube or ng. tube or N.G.T. Nasogastric tube

noct At night

NP Neuropsychiatric or nursing procedure

NPO or N.P.O Nothing by mouth

nsy Nursery

O2 Oxygen

OB or O.B. Obstetrics

Obt or obt. Obtained

OJ or O.J. Orange juice

Orb. Orderly

OOB or O.O.B. Out of bed

OPD or O.P.D. Outpatient department

OR or O.R. Operating room

Ortho Orthopedics

OT or O.T Occupational therapy or oral temperature

oz. Ounce

PAR or P.A.R. Postanesthesia room

Pc After meals

Ped or Peds Pediatrics

Per by, through

p.m. or P.M., pm or PM Afternoon

PMC or P.M.C Postmortem care

PN or P.N. Pneumonia

po By mouth

post or p after

postop or post op Postoperative

post op spec After surgery urine specimen

PP Postpartum (after delivery)

PPBS Postprandial blood sugar

pre Before

prn or p.r.n. Whenever necessary, when required

preop or pre op Before surgery

pre op spec Urine specimen before surgery

prep Prepare the patient for surgery by shaving the skin.

Pt or pt Patient; pint

PT or P.T. Physical therapy

q Every

qd Every day

qh Every hour

q2h Every 2 hours

q3h Every 3 hours

q4h Every 4 hours

QHS or qhs Every night at bed time/ hour of sleep

qid or Q.I.D. Four times a day

qam or q am or q.a.m. Every morning

qod or Q.O.D Every other day

qs Quantity sufficient, as much as required

qt quart

r or R rectal or Rectal

Rm or rm Room

RN or R.N. Registered nurse

Rom or R.O.M. Range of motion

RR or R Rm. Recovery room

Rx Prescription or treatment ordered by a physician

s or ? Without

S&A Sugar and acetone

S&A test or S.& A. test Sugar and acetone test

S&K or S.& K. test Sugar and ketone test

SOB Shortness of breath

sos Whenever emergency arises; only if necessary

SPD Special purchasing department

Spec or spec. Specimen

ss or ?? One-half

SSE or S.S.E. Soapsuds enema

Stat At once, immediately

STD Sexually transmitted disease

Surg Surgery

tid or T.I.D. Three times a day

TLC or tlc Tender loving care

TPR Temperature, pulse, respiration

TWE Tap water enema

U/a or U/A or u/a Urinalysis

Ung. Ointment, unguentine

VDRL Test for syphilis

V.S or VS Vital signs

WBC or W.B.C. White blood count

w/c Wheel chair

wc or W.C. Ward clerk

wt Weight

Medical/Nursing Abbreviations & Acronymns

For us health care workers, to effectively communicate either through oral communication and documentation, we

should be knowledgeable about the different abbreviations and acronyms.

The following is a short list of the different abbreviations and acronyms the health-care industry have:

A /G = albumin/globulin ratio

AAL =  anterior Axillary Line

ABG = arterial blood gases

AC = before eating

ACE = angiotensin converting enzyme

ACL = Anterior Cruciate Ligament

ACLS = advanced cardiac life support

ACTH = adrenocorticotropic hormone

ADH = anti-diuretic hormone

ADL = activities of daily living

ADSF = Anterior Decomposition Spinal Fusion

AFB = acid-fast bacilli

AFP = alpha-fetoprotein

AGA = appropriate for gestational age

AGN = Acute Glomerulonephritis

AI = aortic insufficiency

AIDS = acquired immune deficiency syndrome

AKA = Above Knee Amputation

AKA = above knee amputation

ALD = alcoholic liver disease

ALL = acute lymphocytic leukemia

ALP = alkaline phosphatase

ALT = alanine transaminase, alanine aminotransferase

APR = Abdominoperineal Resection

ARF = Acute Renal Failure

ASA = Acute Surgical Abdomen

ATN = acute tubular necrosis

AU = both ears

AV = atrioventricular

ad lib = as much as needed

B.S. = Bachelor of Science

B/K = below knee

BAT = Blunt Abdominal Trauma

BIH = Bilateral Inguinal Hernia

BKA = Below Knee Amputation

BM = bowel movement or breast milk

BX = biopsy

c = with

C/O = complaining of

CA = calcium, cancer, carcinoma

CAA = crystalline amino acids

CABG = coronary artery bypass graft

CAD = coronary artery disease

CAPD = continuous ambulatory peritoneal dialysis

CAT = computerized axial tomography

CA = Cancer

CBC = complete blood count

CBD = common bile duct

CBDE = Common Bile Duct Exploration

CBD = Common Bile Duct

CBG = capillary blood gas

CBI = continuous bladder irrigation

CBS = capillary blood sugar

CC = chief complaint

CCK = cholecystokinin

CCPD = continuous cyclic peritoneal dialysis

CCU = clean catch urine or cardiac care unit

CCV = critical closing volume

CF = cystic fibrosis

CHF = congestive heart failure

CHO = carbohydrate

CI = cardiac index

CKD = Chronic Kidney Disease

CLEA = Continuous Lumbar Epidural Anesthesia

CLT = Clinical Laboratory Technician

CML = chronic myelogenous leukemia

CN = cranial nerves

CNS = central nervous system

CO = cardiac output

COM – Chronic Otitis Media

COPD = chronic obstructive pulmonary disease

CP = chest pain, cleft palate

CPD = cephalo-pelvic disproportion

CPK = creatinine phosphokinase

CPP = cerebral perfusion pressure

CPR = cardiopulmonary resuscitation

CRCL = creatinine clearance

CRF = chronic renal failure

CRT = capillary refill time

CSF = cerebrospinal fluid

CT = computerized tomography

CVA = cerebral vascular accident, costovertebral angle

CVP = central venous pressure

D3 = Distal Third

D5W = 5% dextrose in water

DAT = diet as tolerated

DC = (dc) discontinue

DIC = disseminated intravascular coagulopathy

DIH = Direct Induinal Hernia

DKA = diabetic ketoacidosis

DL = Direct Laryngoscopy

DM = diabetes mellitus

DNA = deoxyribonucleic acid

DNR = do not resuscitate

DOA = dead on arrival

DOE = dyspnea on exertion

DPT = diphtheria, pertussis, tetanus

DTR = deep tendon reflexes

DVT = deep venous thrombosis

DX = diagnosis

EAA = essential amino acids

EBL = estimated blood loss

EBV = Epstein-Barr Virus

ECCE = Extra Capsular Cataract Extraction

ECF = extracellular fluid, extended care facility

ECG = electrocardiogram

ECT = electroconvulsive therapy

EDC= Extensor Digitorum Communis

EDH = Epidural Hematoma

EEA = End to end Anastomosis

EEL = Emergency Exploratory Laparotomy

EENT = eye, ear, nose and throat

EFAD = essential fatty acid deficiency

EGD = Esophagogastroduodenoscopy

EMG = electromyogram

EMV = eyes, motor, verbal response (Glasgow coma scale)

ENT = ears, nose, and throat

EOM = extraocular muscles

ERCP = Endoscopic Retrograde Cholangiopancreatography

ESR = erythrocyte sedimentation rate

ESRD = end stage renal disease

ET = endotracheal tube

ETT = endotracheal tube

EUA = examination under anesthesia

FBE = Foreign Body Extraction

FBS = fasting blood sugar

FCU = Flexor Carpi Ulnaris

FDA = Food & Drug Administration

FDP = Flexor Digitorum Profundus

FDS = Flexor Digitorum Superficial

FESS = Functional Endoscopic Sinus Surgery

FEV = forced expiratory volume

FFP = fresh frozen plasma

FIA = Fistula in Ano

FNP = Family Nurse Practitioner

FTSG = Full Thickness Skin Grafting

GB = gallbladder

GC = gonorrhea

GCS = Glascow Coma Scale

GERD = gastroesophageal reflux disease

GETA = General Endotracheal Anesthesia

GFR = glomerular filtration rate

GI = gastrointestinal

GSW = Gunshot Wound

GTT = glucose tolerance test

GU = genitourinary

HB = hemoglobin

HBP = high blood pressure

HCG = human chorionic gonadotropin

HCO3 = bicarbonate

HCT = hematocrit

HD = hemodialysis

HDL = high density lipoprotein

HEENT = head, eyes, ears, nose, throat

HPT = Hemoperitoneum

I & D = Incision & Drainage

IBG = Iliac Bone Graft

ICS = Intercostal Space

IIH = Indirect Inguinal Hernia

IJ = Intrajugular

IOC = Intraoperative Cholangiogram