i thought i had a link to a webpage on this but i can't find it in my files. dar
is a form of focus charting and the dar stands for data-action-response. it ensures documentation that is based upon the nursing process. routine
nursing tasks and assessment data is documented on flow sheets and check lists.
your focus is a nursing diagnosis, or in place of a nursing diagnosis you can use a problem, sign or symptom (nausea, pain, etc), behavior, special need, an acute change in the patient's condition or a significant event. your progress note is written in the dar form.here are four examples of dar charting
d (data) - includes subjective and objective information the describes the focus.
a (action) - includes immediate and future nursing actions based on your assessment of the patient's condition and any changes to the care plan you deem necessary based on your evaluation.
r (response) - describe the patient's response to nursing or medical care.
nausea related to anesthetic
d: pt. states she's nauseated. vomited 100ml clear fluid at 2255focus:
a: given compazine 1mg iv at 2300.
r: pt. reports no further nausea at 2335. no further vomiting.
risk for infection related to incision sites
d: incision site in front of left ear extending down and around the ear and into neck--approximately 6 inches in length--without dressing. jackson-pratt drain in left neck below ear secured in place with suture.focus:
a: assess site and emptied drain. taught patient s&s of infection.
r: no swelling or bleeding; bluish discoloration below left ear noted. jp drained 20ml bloody drainage. patient states understanding of teaching.
delayed surgical recovery
d: patient reported dizziness after trying to get oob to use the bathroom.focus:
a: assisted patient back in bed and with use of bedpan. taught patient how to dangle legs and get oob slowly. also taught coughing and deep breathing exercises, turning in bed, and use of entiembolism stockings.
r: patient voided 200ml in bedpan. did cough and deep breathing appropriately. lungs clear bilaterally. using antiembolism stockings.
acute pain related to surgical incision
d: patient reports pain as 7/10 on 0 to 10 scale.
a: given morphine 1mg iv at 2335.
r: patient reports pain as 1/10 at 2355.
all of the above is from page 678 of portable rn: the all-in-one nursing reference
, third edition, published by lippincott, williams & wilkins, 2007