BSN-4A3
Dalde, Christine Emily P.
Name: __________________________________________________________
May 16, 2024
Date: ___________________
CEU MAKATI
FDAR DOCUMENTATION
FOCUS
Risk for fall
(dizziness caused
by vertigo)
DATA
Subjective:
"Sumasakit yung ulo niya tas nahihilo, nung last
week niya pa nararamdaman," as verbalized by
the patient's relative.
"Nahihilo pa rin ako," as verbalized by the patient.
Objective:
BP = 110/80
RR = 22
ACTION
1. Ensure the patient is in a safe position to prevent injury.
2. Padded both side rails up.
3. Assess the patient's functional abilities.
4. Administer oxygen to improve oxygen saturation.
5. Start an IV line for administration of fluids.
6. Monitor vital signs continuously.
RESPONSE
- Patient has stable vital signs.
- No episodes of fall.
- Patient does not report
dizziness.
RUBRICS FOR FDAR DOCUMENTATION
Assignment
Criteria
Excellent 5
Very Good 4
Good 3
Fair 2
FOCUS
The learner’s focus of the scenario
was accurate and appropriate,
patient specific/centered or
captured a significant event in the
patient’s care.
The learner’s focus of the scenario
was accurate and somewhat
appropriate, patient
specific/centered or captured a
significant event in the patient’s
care.
The learner’s focus of the scenario
was lacking in specificity, captured
only chronic not acute issues of
patient centered care.
The learner’s focus of the scenario
was not accurate nor appropriate,
was not patient specific/centered or
captured a significant event in the
patient’s care.
DATA
The learner collected specific data
which is subjective and/or objective
information, supports the stated
focus or describes observations, sign
and symptoms, significant
investigations and/or other
assessments at the time of
significant treatment.
The learner collected data which is
subjective and/or objective
information but does not support
the stated focus or describes
observations, sign and symptoms,
significant investigations and/or
other assessments at the time of
significant treatment.
The learner collected specific data
which is not subjective and/or
objective information. Data loosely
supports the stated focus or
describes observations, sign and
symptoms not present, significant
investigations and/or other
assessments at the time of
significant treatment.
The learner did not collect specific
data which is subjective and/or
objective information, lack of
support for the stated focus, does
not describe observations, sign and
symptoms, significant investigations
and/or other assessments at the
time of significant treatment.
X2
Intervention(s) or action(s)
performed on an analysis of the
information gathered through
observation, investigation and
assessment.
Interventions/actions are clear, and
accurate/applicable, missing some
assessment components.
Interventions/actions are somewhat
unclear, and accurate/applicable,
missing some assessment
components.
Intervention(s)/ action(s) are lacking
on an analysis of the information. No
observation, investigation and
assessment noted.
X2
A description of the patient’s
response to actions and
interventions and/or the patient’s
progress toward goals: the impact of
the intervention on the patient are
complete.
The recording of the patient’s
response to actions and/or the
patient’s progress toward goals and
in impact on the intervention is
mostly complete, lacking some
explanation.
A description of the patient’s
response to actions and
interventions and/or the patient’s
progress toward goals; the impact of
the intervention on the patient is
somewhat complete though unclear.
A description of the patient’s
response to actions and
interventions and/or the patient’s
progress toward goals; the impact of
the intervention on the patient are
not present or incomplete.
ACTION
RESPONSE
SCORE
TOTAL
Compute for the Grade:
(Score divided by 30) x 50 + 50
Drug Study Grade: ______________________
Clinical Instructor: _____________________________