TRANSCRIBING DOCTORS ORDER
AND FDAR CHARTING
DOCUMENTATION
NURSING DOCUMENTATION
-Important for it serves as a written evidence
for :
1. The interactions between and
among healthcare
professionals, clients, their
families, and healthcare
organizations.
2. The administration of tests,
procedures , treatments, and
clients education.
3. The results of diagnostic tests
and clients clients response to
intervention, thus, each
health care provider is
responsible for the ABC’s of
recording
A- Accuracy
B- Brief
C- Complete
DEFINITION OF TERMS
Documentation – Written/electronically
generated information of clients that
describes the care or service provided to
them.
Medical or Doctors order- Written/Verbal
order made by physician pertaining to the
care and management of the client.
Nurses are responsible for maintaining
accurate records of the care they provide to
the clients. Thus, making us accountable if
information is incomplete or inaccurate.
One of the responsibilities of nurses is :
1. Transcribing or carrying out of
Doctor’s order (CDOs)
2. FDAR CHARTING or writing the
progress notes.
CARRYING DOCTOR’S ORDERS
(CDOs)
 Done after the physician’s
rounds
 Done to admit and discharge
clients
 Done while clients are in the
hospital
COMMON PROBLEMS AND
CHALLENGES IN CDO’S
1. Physician’s hand writing – difficult
to read and transcribe
2. Delay of actions
3. Lack or no attachments
e.g prescription or laboratory requests
4. Shortcuts of physician’s order
Things to remember in CDOs
- Trying reading the order yourself
- Ask assistance if unable to read
- Check new terms or medications in
books or other references
- Never skip an item or those you find
difficult to read
 - Do not sign unless you have fully
transcribe the oder
- All and every order must be written
in the KARDEX.
KARDEX- Medical information system
used by nursing staff as a way of
communicating important information
about the client and a quick summary of
individual client’s nursing treatment that
is updated at every shifty-change.
-Nursing procedures are performed
before signing them.
What is Record or Chart?
- The systematic documentation of a
single patient’s medical history,
clinical data and care across time.
What contains the patients record or
chart?
Cover page/ Front page
In CRMC, their front page/ cover
page is usually color-coded, to help
healthcare professional or health care
providers determine what department the
patient is admitted.
White – Medicine
Yellow- Pedia
Blue- OB
Green- Surgery
KARDEX- is the summary of the needs and
treatments provided to the client.
What Contains the Kardex?
Above -the baseline information of the client
Below- The treatments provided/given to the
client.
o IVF, different diagnostic and
laboratory tests given, blood
transfusion, medications, and other
treatments.
Doctor’s order contains:
Above -the baseline information of the client
First column- Date and Time
Second column- Order
Next- CARED- Carried, Administered,
Request made, endorsed, Discontinue
Last- Time and Signature
Vital Signs Record contains:
Above -the baseline information of the client
Below are the ff;
-Date
-Shift and time
-BP
-Pulse rate
-Respiratory rate
- Temperature
-O2 Saturation
-PVC
- Weight
-Abdominal Girth
IV Flow sheet
Above -the baseline information of the client
First column- Bottle number
Second column- Type of IVF
Third column- Date and time hooked
Next- Nurses signature
Last- The date and timed consumed,
signature and remarks
LIST OF MEDICAL SUPPLIES
RECEIVED FOR THE PATIENT
-this form is usually filled up when you
receive medications or fluids from the client,
you need to record all the supplies you
received from the client for further
references.
Medication sheet- where we write the
medicines of the clients.
It contains:
Above -the baseline information of the client
First- Medication, dosage, frequency of
administration
Second column- shift
Next- Frequency
Below- signature of the staff who gave the
medication
Medication tickets- are color-coded.
White- Once a day/ stat or single dose
Yellow- Two times a day (BID)
Hours of sleep (8pm)
Every 12 hours
Pink- Three times a day (TID)
Every 8 hrs, every 6 hrs
Blue- Four times a day (QID)
Every four hours
IV TAG- Is used for intravenous fluid.
It contains:
Name, Room/ward, IVF, Incorporation,
Date/time hooked, frequency , and signature
PROGRESS NOTES/ NURSES NOTES
Above -the baseline information of the client
Below- Dat,e time and shift(First column),
Focus (Second Column), Data, action,
response (third column)
HOW TO CARRY OUT DOCTOR’S
ORDER?
Need to prepare the ff forms:
-Doctor’s order
-Kardex
-Medication Tickets
-Medication sheet
-Nurses notes
Carrying out doctor’s order
 Carefully read doctor’s order
 Prepare needed forms
 Transcribe all orders in kardex
 Fill up the doctors form
 Transcribe on form as indicated
In carrying out the doctor’s order, the
nurse should transcribe all the orders in the
kardex.
Using a red ballpen, underline the spaces
on every after each entry ; ensures that
physician cannot insert new orders.
Check the CARED box for each order
done using a blue or black ballpen
Check C if it’s carried out, A if
administered, R if you made a request, E id
endorsed, and D id discontinued
Affix signature at each every order done
Affix signature, complete name ,
designation, licensed no. signature and time
the order was carried out.
 WRITING OF NURSES NOTES/
PROGRESS NOTES
METHODS (STYLES) OF CHARTING
OR DOCUMENTING
1. NARRATIVE- most familiar
method of documenting nursing care.
In a diary or story form, written in
chronological order. It is used to
document patient’s status, care,
events, treatments, intervention, and
patient’s response to the
intervention.
2. SOAP (SOAPIE/SOAPIER)-
originated form the medical model.
Documentation is focused in
patient’s problem , that is why it is
called “ Problem Oriented”.
However, it reflects
onlycertain aspect of the nursing
process. It does address the
evaluation process of nursing care.
Thus , it was modified into SOAPIE/
SOAPIER wherein evaluation,
implementation, and revision are
added.
3. FDAR / Focus charting-is not only
limited to clinical problems , it may
include client’s concern or behavior ,
a change in the patient’s status and
condition.
This type of charting is
patient –oriented .
4. PIE- also an example of problem-
oriented charting format that arouse
from the nursing process . This
system of charting consists of a
patient’s care, assessment, flow
sheet, and progress notes.
FOCUS CHARTING OR FDAR
Kozier and Erb
Focus charting or FDAR is a method of
organizing health information in an
individual client and record wherein the
client and client concerns and strengths are
the focus of care.
GENERAL GUIDELINES IN FOCUS
CHARTING
 Focus charting must be written
atleast once every shift
 Patient-oriented not nursing task-
oriented .
Patient oriented -care provided by
nurses should be respectful and
responsive to individual client’s
needs
nursing task- oriented – care
focusing on completing the task.
Separate the topic words for the body of the
notes:
a. Focus note written on the second
column.
b. Data, action, and response on the
third column.
Nurse should write his/her complete
name, designation, licensed no., affix
signature over printed name in all or
every entry in nurses notes.
- Document only patient’s concern
and/or plan of care.
 - General notes are not allowed. A-ACTION

eamples: Vital signs taken, needs - It reflects the planning and

attended, morning care rendered Implementation phase of the nursing
process.
Document patients status upon - -Immediate or future nursing actions
admission, for every transfer to/from based on the nurse’s assessment/
another unit, discharge evaluation of the client’s condition
-Follow the DO’s of documentation - It may also include any changes to
the plan of care.
-Use BLUE or Black nonerasable ink of
pen for AM and PM shift, red ink for R-RESPONSE
night shift.
-Reflects the evaluation phase of the
F-Focus
nursing process
Focused assessment is a detailed nursing -describes client’s outcome, response
assessment of specific body system (s) or the result of medical and nursing
relating to the presenting problem or intervention.
current concern(s) of the client.
Columns in the chart for
- Problem identifiend form the client. documentation:
- - contains the nursing diagnosis or  Data and Hour (1st column)
the complaints of the client.  Focus ( 2nd column)
D-Data  Progress notes( 3rd column)
(D) data,
Reflects the assessment phase of the (A) action,
nursing process and consists of observations (R) response
of client status and behaviors

- This includes the use of IPPA.

Two types of data

. Objective- are observable and

measurable data (signs) obtained
through observation and physical
examination.

. Subjective- are information from the

client’s point of view (symptoms),
including feelings, perceptions, and
concerns obtained through interview
How to develop the focus

GUIDELINES IN WRITING FOCUS

LIST

- Enter a focus note only when it is

required

-Do not write a focus note because “it’s

time” (end of shift) or because the nurse
want to indicate the he/she observed the
patient at regular intervals.

- remember the goal is to communicate

essential patient information.

To assist the nurse in choosing a focus

Ask self; “What is the focus of my care

or concern for this client?”
“ Is it client related and not treatment
related?”
In CRMC, medications are not written in
progress notes/ nurses notes to avoid
duplication of the medication sheets

“Is it specific?”