Review Format of Progress Notes (DAR)

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Format of Progress Notes (DAR)

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Total Questions : 5

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Question 1:

A nurse is documenting the progress notes of a client who has chronic pain.

The nurse uses the DAR format to record the data, action, and response.

Which of the following is an example of a data entry in the DAR format?

A. Administered ibuprofen 400 mg orally as prescribed. B. Reports pain relief and requests to walk in the hallway. C. Observed facial grimace and guarding of the abdomen. D. Encouraged deep breathing and distraction techniques.

Answer and Explanation

Choice A:

It is an example of an action entry in the DAR format.Action entries describe the nursing interventions that the nurse performed to address the client’s problem or need.

For example, administering medication, providing education, or applying a dressing.

Choice B:

It is an example of a response entry in the DAR format.Response entries describe the client’s reaction or outcome to the nursing interventions.

For example, reporting pain relief, expressing satisfaction, or showing improvement.

Choice C:

This is an example of a data entry in the DAR format because it describes the objective and subjective information that the nurse collected from the client.Data entries can include vital signs, physical assessment findings, laboratory results, and client statements.

Choice D:

It is also an example of an action entry in the DAR format.

It describes another nursing intervention that the nurse performed to help the client cope with pain.

The DAR format is a type of focus charting that helps nurses document problems identified in the client care plan.

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Question 2:

A nurse is using the SOAP format to document the progress notes of a client who has hypertension.

The nurse needs to select all that apply when writing the plan of care for this client.

Which of the following are appropriate components of the plan in the SOAP format?

A. Monitor blood pressure and pulse every 4 hours. B. Educate the client about dietary sodium restriction. C. Assess for signs of orthostatic hypotension. D. Evaluate the effectiveness of antihypertensive medication. E. Identify the risk factors for developing hypertension.

Answer and Explanation

Choice A:

Monitoring blood pressure and pulse every 4 hours is an objective and measurable intervention that can help evaluate the patient’s condition and response to treatment.

Choice B:

Educating the client about dietary sodium restriction is an intervention that can help prevent or reduce hypertension and its complications.

Choice C:

Assessing for signs of orthostatic hypotension is not an intervention, but an observation that belongs to the objective section of the SOAP note.

Choice D:

Evaluating the effectiveness of antihypertensive medication is an intervention that can help assess the patient’s progress and adjust the treatment plan accordingly.

Choice E:

Identifying the risk factors for developing hypertension is not an intervention, but an assessment that belongs to the assessment section of the SOAP note.

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Question 3:

A nurse is using the SOAPIER format to document the progress notes of a client who has diabetes mellitus.

The nurse needs to write an intervention entry in the SOAPIER format.

Which of the following is an example of an intervention entry in the SOAPIER format?

A. “I feel thirsty and hungry all the time.”. B. Blood glucose level is 250 mg/dL before lunch. C. Instructed the client on how to use a glucometer at home. D. Impaired glucose tolerance related to insufficient insulin production. E. “I will check my blood sugar before each meal and at bedtime.”.

Answer and Explanation

Choice A:

It is an example of a subjective entry, which includes anything related to what the patient has told the nurse.This should be recorded exactly as the patient reports and in quotation marks.

Choice B:

It is an example of an objective entry, which consists of any measurable observations that the nurse makes during the patient assessment.This includes vital signs, laboratory results, physical findings, and other data that can be verified.

Choice C:

Instructed the client on how to use a glucometer at home.This is an example of an intervention entry in the SOAPIER format, which stands for subjective, objective, assessment, plan, intervention, and evaluation.An intervention entry describes any actions that were taken to support the patient based on the assessment and plan.

In this case, the nurse provided patient education on how to monitor blood glucose levels at home using a glucometer.

Choice D:

It is an example of an assessment entry, which is the nurse’s interpretation of the subjective and objective information and conclusions regarding the patient’s condition.This may include nursing diagnoses, problem statements, or clinical impressions.

Choice E:

It is an example of an evaluation entry, which describes the result of any interventions and whether they achieved the desired outcomes.This may include patient feedback, changes in condition, or need for further action.

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Question 4:

A nurse is using the focus charting method to document the progress notes of a client who has anxiety.

The nurse needs to write an evaluation entry in the focus charting method.

Which of the following is an example of an evaluation entry in the focus charting method?

A. Demonstrates relaxation techniques such as deep breathing and meditation. B. States feeling nervous and restless before a scheduled surgery. C. Anxiety related to fear of surgical complications and pain. D. “I feel more calm and relaxed after practicing the breathing exercises.”. E. Suggests to postpone the surgery until more information is provided.

Answer and Explanation

Choice A:

It is an example of an action entry, not an evaluation entry.Action entries reflect theplanning and implementation phaseof the nursing process and include immediate and future nursing actions.

Choice B:

It is an example of a data entry, not an evaluation entry.Data entries reflect theassessment phaseof the nursing process and include subjective and objective information about the client’s health status.

Choice C:

It is an example of a focus, not an evaluation entry.A focus is a key word or phrase that identifies the client’s concern, problem, or strength.It can be derived from a nursing diagnosis, a sign or symptom, an acute change in condition, a significant event, or a standard of care.

Choice D:

This is an example of an evaluation entry in the focus charting method because it describes the client’s response to the nursing intervention of teaching relaxation techniques.Evaluation entries reflect theevaluation phaseof the nursing process and show whether the client’s goals and outcomes have been met or not.

Choice E:

it is an example of an action entry, not an evaluation entry.Action entries reflect theplanning and implementation phaseof the nursing process and include immediate and future nursing actions.

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Question 5:

A nurse is using the PIE documentation system to document the progress notes of a client who has pneumonia.

The nurse needs to write an evaluation entry in the PIE documentation system.

Which of the following is an example of an evaluation entry in the PIE documentation system?

A. The client has been coughing less frequently and reports feeling less short of breath. B. The client has a productive cough with yellowish sputum and crackles in the lower lobes of both lungs. C. The client’s oxygen saturation level has improved from 88% to 95% after receiving oxygen therapy for 24 hours. D. The client will maintain a normal oxygen saturation level of at least 92% with supplemental oxygen as needed.

Answer and Explanation

Choice A:

This is an example of an intervention entry because it describes the actions taken by the nurse to address the problem (coughing and shortness of breath).

Choice B:

This is an example of a problem entry because it identifies the signs and symptoms of the health condition (pneumonia).

Choice C:

This is an example of an evaluation entry in the PIE documentation system because it describes the outcome of the intervention (oxygen therapy) for the problem (low oxygen saturation level) using objective data (percentage).

Choice D:

This is an example of a plan entry because it states the expected outcome or goal for the problem (low oxygen saturation level).

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Format of Progress Notes (DAR)

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