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.
The Correct answer and Explanation is:
Correct Answer: C. Observed facial grimace and guarding of the abdomen.
Explanation:
The DAR (Data, Action, Response) format is a structured method of documentation in nursing, often used in focus charting. It allows nurses to organize their notes in a way that clearly shows the patient’s condition, the interventions taken, and the patient’s response to those interventions. Each component of the DAR format serves a specific purpose:
- Data (D): This section includes subjective and objective information about the client’s condition. It captures the current situation or problem, and it often involves observations made by the nurse, patient statements, or relevant clinical findings.
- Action (A): The action part involves documenting the interventions or nursing actions taken in response to the data. This might include administering medication, providing education, performing a procedure, or other care-related activities.
- Response (R): The response section records the patient’s response to the nursing interventions. This can include changes in the patient’s condition, feedback from the patient, or the outcome of the interventions.
Given these definitions, the correct example of a data entry is C. Observed facial grimace and guarding of the abdomen. This statement reflects the nurse’s observation, which is objective data concerning the client’s condition. It details specific signs that indicate the client is experiencing pain, which is essential information when managing chronic pain.
The other options represent different parts of the DAR format:
- A. Administered ibuprofen 400 mg orally as prescribed is an action entry, as it describes the intervention taken by the nurse to manage the client’s pain.
- B. Reports pain relief and requests to walk in the hallway is a response entry because it indicates the client’s reaction to the treatment and how they feel afterward.
- D. Encouraged deep breathing and distraction techniques is another action entry, detailing what the nurse did to help manage the client’s pain.
Understanding how to properly categorize each component in the DAR format ensures accurate and organized documentation, which is crucial for ongoing patient care and communication among healthcare team members. Proper documentation helps in tracking the client’s progress, making informed decisions, and providing high-quality, consistent care.