Dar Charting 4h1d6k

DAR Charting Nurses’ Progress Notes Date and Time Date Time

Patient’s Diet

Notes

Focus: Problems/needs of the patient (PRIORITIZE)

> Received on bed----D > Subjective data – verbalized by the patient > Objective data – can be observed and measured A > Diagnostic/Therapeutic / Educative Interventions / Dependent / Independent Interventions and health teachings - Kinds of monitoring done + indicate the time - Above IVF/ BT consumed and replaced / removed + indicate the time - Referrals to ROD + indicate the time and actions taken R > Subjective / Objective response of the patient > Endorsed------

DO’s • If you will write the patients diet, write the percentage of food consumed with good, fair or poor appetite and type of diet. No DAT write full/soft in line with the appetite of the patient. If the patient will be on NPO post midnight, instruct the patient. If the patient is on OF, you can write NGT feeding done. For Example: Patient’s Notes Diet Full

> Received on bed----D> A > Consumed 100 % of food served with good appetite R> > Endorsed-----

Instruct the patient and watchers about patient’s • CBR without BRPs / CBR with BRP’s strictly • Only STAT order of meds will be reflected on nurse’s notes. No STAT orders in Treatment A, only standing orders. • Writing MUST be clear and easily read by others. • Use only those abbreviations approved by the institution • Color coding of ball pen in charting: • 7-3 = Black Ink 3-11 = Blue ink 11-7 = Red • Color coding of ball pen in TPR Plotting: Temp: black/blue PR: Red Ink RR= • Black/Blue Ink •

DON’TS: • Avoid charting the following:  Afebrile  With May Go Home Order  Diet as Tolerated  Rounds done  Needs attended / Attended to Needs  Kept warm  Promoted safety  Promoted rest and comfort  Due meds given  Vital signs taken and recorded signs can be seen in the  Monitored accordingly treatment sheet

Correct errors by drawing a single, horizontal line through the error. Write the work “mistaken entry” above the line, then your initials and date, then write the correct work beside the incorrect work. No ink eradication, erasures or use of occlusive materials. Mistaken entry

For example: Temp = 100 beats/min PR: 100 bpm If there are diagnostic procedures / intubation done with the patient, be specific on the diagnostic procedures and the names of the resident on duty who did the procedure. Endorse properly. Indicate the number and level of IVF, sidedrip with correct duration and ongoing blood transfusion. Endorse what is not done through Kardex.

If you will write these interventions be more specific

It is already a given nursing intervention because vital vital signs sheet and medications can be seen in the

 Hooked IVF/ BT -----Use the word “inserted” or replaced”  Seen and examined by “Resident on Duty / ROD”. Be more specific  Received “patient”. Do not put the word “patient” on charting because all information in the chart

already pertains to patient itted to ward-----Write “Received from ER-----“Because the patient is already itted in E.R. Endorsed to next shift for further care and management / continuity of care. o Be specific on what you are going to endorse. For example, you can write “Endorsed with ongoing IVF of -----“ o If patient has no IVF, you can write “Endorsed with latest vital signs of -----“  Went home-----You can write Discharged with improved health status, ambulatory and accompanied by -----“  When a patient will be discharged because of HAMA, use the words “Went home against Medical Advice”.  