Trouble with charting...DART (focus)

[FreshRN05]

I am getting so stressed out and frustrated. I am still in my orientation at work and I am finding it very difficult to chart. Our hospital use DART (data, action, response, treatment) style. I know it seems easy and self explanatory but I am having difficulty following the format. I spend tremendous time finishing my charting because I just can't seem to find the right words to write. Can someone explain thsi type of charting to me in maybe a layman's term.....maybe give me examples or a website I can go to to learn the proper way of charting. And also legally speaking what are the things that you can't write on a patient chart? Please helppppppppppppppppp....

[Indy, LPN, LVN]

These acronyms give me a headache. Seriously, is action not the same thing as treatment? Who comes up with this stuff?

D= assessment data. What is going on with the patient.

A= What did you do.

R= then what? Did it work?

T= I dunno what on earth I'd put for treatment. Sounds like if the charting was done right then it'd already be covered. Maybe what you intend to do ... like "will cont to monitor?"

I think for some notes all the letters may not apply. And I usually mix up my DAR and do DRA because I hate for stuff to not make sense when you read it back. DAR: Assessment data, will continue to monitor, no complaints, no distress. DRA: Assessment data, no complaints, no distress noted, will continue to monitor. See the difference? Sometimes "no complaints" is in there just to show I paid attention to someone when they are sound asleep.

And if I have to do the narrative for chest pain and/or patient going downhill then well, DAR goes out the window. I put assessment data, then write "care as follows" and just list time: very short data and action. Like serial nitro's with blood pressures every five minutes followed by morphine for chest pain. That is going in one note, sorry and I'm not going to make 3-4 different DAR notes for chest pain.

If you really have trouble with it, and you have time, read the other nurses notes and see how they organize their stuff. It'll give you some good ideas.

[Indy, LPN, LVN]

Hmm, forgot to answer your other question. What can you not write? Well most employers don't like you to mention a variance if you have to write one up. Don't pre-chart. If you are going to do it but haven't done it yet, don't put pen to paper. That thing alone can cost you your license. It's nice to avoid subjective opinions of the patient in your language. Instead of "refused" I like the word "declined" as it doesn't bring any emotional context with it, as in "patient declined a bath both times it was offered."

You can chart what the patient says if you put it in quotes and get it as close as you can remember, to what the patient actually said. If you don't want to quote you can use language like "patient reports satisfactory pain relief."

[Lorie P.]

have you ckecked to see if you can use narrative?? we use dar ....but we can also use narrative........ check you policies and procedures....ours are on line at work and i am always looking at them......so much that others ask me to look something up for them or ask where they can find a certain policy.....

[Hobbitk14]

I am a first semester nursing student a with a class objective of describing how to use DART charting and am finding most refer to the T as teaching not treatment. This may or may not be your establishments policy, If you have figured it out could you please let me know,