Tips for Psych RN Charting

Published

Hello All, I know this was asked before but I'm curious about how others go about writing their DAR notes (or specific form they use) with objective data to protect themselves legally if ever called into court. I guess I'm looking for help on how to make my DAR note informative and useful (like it explains how the pt is doing) but also does not get me into a bind legally in 7 years. A lot of people on the unit use a template, which I think is great but sometimes it feels not pt specific. 

Example format

Data: C.M. is a 56 y/o male with a diagnosis of MDD admitted on 4/5/2026 d/t suicidal ideation. Objective data?

Action: Adminstered medications per MD orders (see eMAR). Offered 1:1 therapeutic communication. Encouraged pt to attend therapy groups. Assessed pt for safety. 

Response: Pt denies SI/HI/AVH. Pt ....

 

If you have any templates or tips you use please let me know. 

Thank you in advance for the advice!

Up Vote Up Vote ×
+ Join the Discussion