DAR Note Help
- 0Oct 1, '07 by krazykevCan someone please help me with writing a DAR Note? I understand that this is a simple idea, but I am really struggling with writing one.
- 2Oct 1, '07 by deeDawnteeIt stands for data, action, response:
Here would be a simple example:
D: Patient's temperature at 1305 was 101.5 (oral). The rest of his vitals were stable and he was in no acute distress.
A: Called Dr Smith and he ordered blood cultures X2, a CBC and a portable chest X-ray. After blood cultures were drawn, patient was given Tylenol at 1400.
R: By 1500 patient's temperature was 99.8 (oral). Lab and X-ray results are pending. Will continue to monitor closely.
So, the Data part is just what is going on...(and sometimes what is not going on, to show that you were checking the whole patient...like above).
Action: What you did about it.
Respose: What was the response of your action?
I almost always add "will monitor or continue to monitor" to show that I intend to stay on top of the situation.
I hope that answers your question. Do you have any examples you want to ask about?
- 4Oct 1, '07 by Daytonitei 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.
focus: nausea related to anesthetic
d: pt. states she's nauseated. vomited 100ml clear fluid at 2255focus: risk for infection related to incision sites
a: given compazine 1mg iv at 2300.
r: pt. reports no further nausea at 2335. no further vomiting.
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: delayed surgical recovery
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.
d: patient reported dizziness after trying to get oob to use the bathroom.focus: acute pain related to surgical incision
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.
d: patient reports pain as 7/10 on 0 to 10 scale.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
a: given morphine 1mg iv at 2335.
r: patient reports pain as 1/10 at 2355.
- 0Mar 27, '12 by ScruffyfyHi! This is a great response to the above question...I have a follow-up question though, I'm a bit confused about some things...How about if the patient has several problems like you had in your examples, is it necessary to separate each problem and then proceed with the next? 'coz in the ward, where I am assigned at, I observed that my colleagues just write everything under DATA like the assessment, the problems etc...and in the ACTION all of the things that they did in response to D were also written under it and so on and so forth.. Is this ok or not? thanks
- 0Mar 27, '12 by GrnTea, BSN, MSN, RNyes, you would note what you assessed and did and plan to do for each problem. whether you do it one at a time or in aggregate, in my opinion, is entirely up to you. what's the purpose of your documentation? to show that you are observing, acting, and planning about your patient. if your documentation does this completely and accurately -- and legibly-- you're doing fine.
- 0Mar 29, '12 by ScottE,RNI was instructed that it is completely inappropriate to chart "Will continue to monitor." That's your job! To monitor the status of your assigned patients and their response to treatments. That's what I have been instructed at least. Which makes complete sense.
D: Patient Bleeding Profusely
A: Told patient to stop bleeding.
R: Patient still bleeding. Will continue to monitor.