Help with dar/focus charting

"in the last 24 hrs urinary output has been diminishing. pt has indicated that he feels as though he is not emptying his bladder despite needing to void more frequently. this am his bladder was distended and he is unable to pass his urine. he is quite uncomfortable and anxious, and is requesting tylenol es tab i for relief of a frontal headache. he is continent and successfully emptied his bowels yesterday.

his physician has just ordered a #12-10cc foley catheter to continuous drainage to be inserted immediately to relieve urinary retention. vs: 168/92-88-20 temp -36c "

"the charting is in focus/dar format... data/action/response"

your data is going to be all of your subjective and objective data. i would start with the subjective data and then move to the objective data because in that order it will show that you did an action which is to assess. the whole note isn't going to follow the dar format exactly from beginning to end because you have several things going on here that each need their own intervention.

basically this format is asking you to note your assessment (subjective/objective info), your interventions/action (what did you do once you assessed this pt?) and the the response you got because of your intervention (an example of this would be to do another note about an hour later reassessing your pt's pain score and the fact that you notified the doc).

i sure hope this helps. the more charting you do, the easier it will get.

data

action

response

example........"pt feels they are not emptying bladder feels need to void more frequently. palpated bladder, distension noted and pt not able to pass urine. pt c/o being uncomfortalbe, anxious, pain. pain and ha 6/10 gave tylenol es. pt continent of bowel. lbm (yesterday's date). vs: bp168/92 p88 r20 t36c. dr notified."

"foley inserted. 12fr 10 ml balloon to gravity. no pain during insertion draining clear yellow urine. 1000 ml out. reassessed pain. now 1/10. pt states "i feel so much better".

Okay, This is what I've done.. tell me what you think. I left out the bowel stuff since he's continent and we chart only things that are out of the ordinary.. I don't really think it needs to be on there.

Focus: Urinary retention

Data: Pt feels they are not emptying bladder despite the need to void more frequently. Urinary output significantly declined in last 24 hrs. Last void 16 hrs ago.

Action: Palpated bladder, distension noted and pt unable to pass urine. Foley inserted as ordered by Dr. smiley to relieve urinary retention. 12Fr 10 mL balloon to gravity.

Response: Pt indicated no pain during insertion. Draining clear yellow urine. 1000 mL out

Focus: Frontal headache

Data: Pt is requesting pain medication for relief of a frontal headache that started approx 1 hour ago. Pt c/o being uncomfortable and anxious. Pain is rated at 6/10 on pain scale. VS: BP168/92 P88 R20 T36C

Action: Notified Dr who advised Pt be given Tylenol ES tab i. Writer administered Tylenol ES tab i as directed to pt.

Response: Reassessed pain. Now 1/10. Pt states "I feel so much better".