FDAR (print in 3 copies - 3 circu opportunities)
DATE/TIME FOCUS DATA ACTION DATE/TIME RESPONSE
8/20/2023 Post transfer Received from Nurse ________, Pre-op checklist reviewed for 8/20/2023 Pre-op checklist complete; BP= ____ mmHg; PR = ____
7:20 AM assessment/i awake, conversant with IVF of completeness; transferred to OR 7:30 AM bpm; RR = _____ cycles/min; O2 sat= ____ %;
Can be found at mmediate _____x____/hr attached to L/R stretcher; side rails raised; brought to OR Start by VS
the nurses preoperative _____________ vein with ____ cc # ______; transferred and secured to OR taken by you CI sign/ SN sign/Staff sign
progress notes care remaining; with heplock attached to table; attached to monitors; inhalation
R/L _____ vein; with NGT attached to started at ___ lpm via nasal cannula; If there are
L nostril clamped or draining to approx. prepared for induction. abnormal
15 ml of yellowish secretions; with values, wait
elastic bandage in place; with skeletal CI sign/ SN sign/Staff sign until there are
traction attached to 2.2 lbs weight; with no changes in
signed consent for the monitor
_______________________________
_______________________________
_______________________________
_______ under (type of
anesthesia)_____________________
_______________________________
______________
CI sign/ SN sign/Staff sign
7/20/2024 Intraoperative Induction of Placed on ___________position for 7/20/2024 BP _____ mmHG
7:35 AM care _______________________________ induction; placed on supine position; fixed 9:50 AM PR _____ bpm
Time of induction (Type of anesthesia) done by Dr. at OR table with upper extremities RR_____ cycle/min
(from ________/ Dr. ________; procedure supported by armboard; FC inserted by Closest vital 02 Sat _____%
anesthesiologist) started by Dr. ______________ and PGI or CC _______________ (closest signs time after Sponges, needles, and instruments complete.
assisted by Dr. _________ and Dr. vital signs time after induction time); final induction time
_________ at ______ AM/PM; Skin prep and drawings done aseptically; if dugay, px’s CI’s sign/ SN’s sign
specimen carefully removed at initial counting of sponges, needles, and response STAMP / STAMP
___:___ AM/PM (if CS: delivered to a _______ done; continuous monitoring during Staff nurse’s
stamp and sign
live baby boy at ____:___ AM/PM; done; specimen secured and properly induction
placenta delivered via Schultze’s or labeled; final count of sponges, needles,
Duncan’s mechanism); procedure and instruments done; closure layer by
ended at ___:___ AM/PM. layer done, betadine painted at
_____________ the sutured site; top
CI’s sign/ SN’s sign dressings applied.
STAMP / STAMP
Staff nurse’s CI sign/ SN sign/ Staff sign
stamp and sign
Prepared by: BSN3A RLE Group 3
7/20/2024 Immediate S/P Brought to PACU per stretcher with side 8/20/2023 BP _____ mmHG
7:35 AM Postoperative _______________________________ rails raised; attached to monitors; 02 10:30 AM PR _____ bpm
Once the patient Care/Pre-Tra _______________________________ Inhalation started at 1-2 lpm via nasal RR_____ cycle/min
has entered nsfer _______________________________ cannula; thermoregulated; endorsed to Based this on 02 Sat _____%
PACU Assessment _______________________________ Nurse _____ (Surname) at ____ AM/PM. the time the
_______________________________ patient was CI.s Sign/ S.N.s Sign
CI.s Sign/ S.N.s Sign Stamp / Stamp
_______________________________ attached to Staff Nurses Stamp and Sign
Stamp / Stamp
(indicate procedure performed based Staff Nurses Stamp and Sign
cardiac
on the operative record); monitor
Drowsy; with IVF of _______ x __ cc/hr
attached to _________ vein; with
heplock attached to ______ vein; with
elastic bandage in _______ with
colostomy at ________ abdomen; with
FC attached to urobag draining to
approx. _______ cc of urine; with
_____ drain draining to approximately
______ cc of colored discharges; with
dressing, dry and intact.
CI’s sign/ SN’s sign
STAMP / STAMP
Staff nurse’s
stamp and sign
Prepared by: BSN3A RLE Group 3