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Format of Progress Notes (DAR)

D: DATA (assessment phase): e.g., facial grimace, rates pain at 4/10.

A: ACTION (planning and implementing): Reflects planning and implementation, e.g., Administer paracetamol 500 mg every 4 hrs.

R: RESPONSE (evaluation phase): e.g., Rates pain at "2". States willingness to ambulate.

Format of Nursing Progress Notes

SOAP: An acronym for subjective, objective, assessment, and planning.

S: Subjective data consists of information obtained from what the client says.

O: Objective data consists of information that is measured or observed using the senses.

A: Assessment is the interpretation or conclusions drawn about the subjective and objective data.

P: Plan of care designed to resolve the stated problem, the initial plan is written by the person who enters the problem into the record.

Examples of Nursing Progress Notes

SOAPIER: add intervention, evaluation, revision.

I: Intervention refers to the specific interventions that have actually been performed by the caregiver.

E: Evaluation includes client responses to nursing interventions and medical treatment.

R: Revision reflects care plan modifications suggested by the evaluation.

Documentation System

  • Problems, Interventions, and Evaluation Documentation (PIE)

  • PIE is an acronym for problems, interventions, and evaluation of nursing care. This system consists of a client care assessment flow sheet and progress notes.

Flow Sheet

  • Use specific assessment criteria in a particular format. The time parameters for a flow sheet can vary from minutes to months. Examples include a graphic record and fluid balance.

Focus Charting

Focus Charting is intended to make the client and client concerns and strengths the focus of care. It has three columns for recording:

1. Date & Time

2. Focus: May be a condition, a nursing diagnosis, behavior, signs and symptoms, or an acute change in client condition or client strength.

3. Progress note (data, action, and response)

Questions on Format of Progress Notes (DAR)

Correct Answer is C

Explanation

<p>It is also an example of an action entry in the DAR format.</p> <p>It describes another nursing intervention that the nurse performed to help the client cope with pain.</p> <p>The DAR format is a type of focus charting that helps nurses document problems identified in the client care plan.</p>

Correct Answer is ["A","B","D"]

Explanation

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

Correct Answer is C

Explanation

<p>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.</p>

<p>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.</p>

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