Format of Progress Notes (DAR)
Format of Progress Notes (DAR) ( 5 Questions)
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?
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.
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.
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.
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.
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.
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 A is wrong because 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 is wrong because 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 D is wrong because 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 is wrong because 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.
Normal ranges for blood glucose levels vary depending on the type of test and the time of day. Generally, a normal fasting blood glucose level is between 70 and 100 mg/dL, while a normal postprandial (after meal) blood glucose level is less than 140 mg/dL. A blood glucose level of 250 mg/dL before lunch indicates hyperglycemia (high blood sugar), which is a common complication of diabetes mellitus.