Question

Please can you explain to me how to do a clinical documentation using DAR Format? Using this scenario: - You are assigned to Mrs. Jones for morning care. While assisting her with her morning bath you notice a purplish-blue bruise on her left hip. When you comment on it, she states that she fell yesterday when getting off the toilet, but didn’t tell anyone. She states the area is sore and moans when it is touched. Her mobility status stated on the care plan is Independent.

Answer 1

FOCUS CHARTING

Focus charting describes the patient’s perspective and focuses on documenting the patient’s current status, progress towards goals and response to interventions.

Objectives of DAR charting

• To easily identify critical patient issues or concerns in the progress notes

• To facilitate communication among all disciplines

• To improve time efficiency with documentation

• To improve concise entries that would not duplicate patient information already provided on the flowsheet/checklist

Application of DAR to the current scinario

In the given case study Mrs. Jones is having purplish blue wound on her left hip as a result of fall. she has pain and tenderness on the area

DAR

1. Data (D)

• It is the assessment phase of the nursing process including vital signs, behaviors, and other observations noticed from the patient.
• Both subjective and objective data are recorded in the data category.

2.​​​​​​​Action (A)

• It includes the planning and implementation phase of the nursing process
• It also incorporates immediate and future nursing actions and changes to the plan of care.

3,Response (R)

• It reflects the evaluation phase of the nursing process and describes the client’s response to any nursing care.

Application

Date and time	Focus	DAR
	Pain and tenderness	Data Subjective data Mrs. Jones reports of sharp pain on the left hip region . Objective data On observation there is purplish blue wound on her left hip and patient appears Moaning while touching the wound Guarding behavior
		ACTION Administered analgesics as per physicians order Insepected Rom of patient related to fracture Encouraged deep breathing exercises and relaxation techniques Kept patient comfortable and safe
		Respose Patient reports pain was slightly relieved