Documentation System
Documentation System ( 5 Questions)
A nurse is using the DAR format to write a progress note for a client who has a history of hypertension.
Which of the following statements should the nurse include as the action?
It is not an action, but a data.
Data is the information that the nurse collected about the client’s condition, such as vital signs, symptoms, or test results.
Data should be factual and objective.
This is the action that the nurse took to address the client’s problem of hypertension.
The action should describe the nursing intervention that was performed to help the client achieve the expected outcome.
It is not an action, but a response.
Response is the outcome or result of the nursing intervention, such as the client’s reaction, behavior, or change in condition.
Response should be measurable and evaluative.
It is not an action, but a focus.
Focus is the reason or purpose for writing the note, such as a nursing diagnosis, a change in condition, or a patient education need.
Focus should be concise and specific.
“Instructed the client on low-sodium diet and exercise.”
This is the action that the nurse took to address the client’s problem of hypertension.
The action should describe the nursing intervention that was performed to help the client achieve the expected outcome.
Choice A is wrong because it is not an action, but a data.
Data is the information that the nurse collected about the client’s condition, such as vital signs, symptoms, or test results.
Data should be factual and objective.
Choice C is wrong because it is not an action, but a response.
Response is the outcome or result of the nursing intervention, such as the client’s reaction, behavior, or change in condition.
Response should be measurable and evaluative.
Choice D is wrong because it is not an action, but a focus.
Focus is the reason or purpose for writing the note, such as a nursing diagnosis, a change in condition, or a patient education need.
Focus should be concise and specific.
DAR format is a method of nursing documentation that stands for Data, Action, and Response. It is a form of focus charting that records significant events or changes in the client’s condition that require nursing care. DAR notes are organized, concise, and informative, and they help to communicate the nursing process and plan of care among health care providers.