Focused Charting

[bth44]

The hospital I work at uses summary charting. I find it's not working for me because I'm too wordy and I go on and on and do a lot of double charting. I'm trying to meet up with a supervisor every so often who's teaching me focused charting, specifically using the D A R method. I believe it stands for Data, Action, and Resolve (?). I feel I'd do better with it if I could read some examples in a book, or at least hear the basics from more than one nurse. This supervisor doesn't have the time to really sit down with me and chart with me at times. Does anyone else here use focused charting? Any websites I can turn to for help? Any examples of what will be good focused charting? I really want to become proficient at this type of charting, but I can't rely entirely on this one supervisor who has their own job to do.

[pricklypear]

A lot of the nurses I work with use DAR charting. I don't, but that's just because...I don't know, I'm kinda wordy, too. PIE is another one I learned in school. Are you having a problem with time management r/t your charting? I only ask because I feel that as long as you chart adequately, covering everything you should be covering, and you're getting all the rest of your work done on time, it shouldn't matter which method you use (if you use a certain one at all). Whatever works for you. Everybody makes such a big deal out of redundant charting, but who cares? As long as everything is being done. I charted excessively when I was new, because that's how I was comfortable - I've calmed down considerably, and can manage to keep it to a minimum.

You're right - D (data) A (action) R (resolution - I think)

An example would be..

1800 D) Pt c/o incisional pain, rated 8/10----------------------------PP

1810 A) Repositioned for comfort, Percocet 5 2 tabs administered-----PP

1910 R) Pt resting, now rates pain at 1/10---------------------------PP

PIE is P (Problem) I (intervention) E (evaluation) Pretty much the same idea.