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Discussion

Tips for Psych RN Charting

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!

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    Think and chart like a reporter:

    Data: C.M. is a 56 y/o male with a diagnosis of MDD admitted on 4/5/2026 d/t suicidal ideation. Patient stated, "I gambled away everything, my wife left me, and I lost my job. I have no reason to live. . . I was going to take the whole bottle of Tylenol. I don't know why I didn't.” No protective factors elicited.

    Action: Administered medications per MD orders (see eMAR). Offered 1:1 therapeutic communication. Encouraged pt to practice gratitude and set SMART goals. Encouraged pt to avoid isolating and attend therapy groups. Pt attended music group but did not engage with music therapist. Assessed pt for safety. Ongoing 1:1 monitoring by MHT in progress.

    Response: Pt denies SI/HI/AVH. Pt rates his depression 7 on a 0-10 severity scale. Stated one of his goals is "to get a job when I get out of here.”

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    Hi there! You said that some nurses use a template; are you charting with a program like Cerner, or is it all free text? I went from a facility that used Cerner, with very few narrative notes, to a facility that is all narrative/free text, and the charting among nurses on my current unit differs a lot from nurse to nurse. I just make sure I always include direct quotes from the patient whenever possible, safety issues including SI/HI/AVH, behavior, affect, etc...I have my own checklist I use, but I kind of wish we had something more standardized. 

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