Format of Progress Notes (DAR)
Format of Progress Notes (DAR) ( 5 Questions)
A nurse is using the focus charting method to document the progress notes of a client who has anxiety.
The nurse needs to write an evaluation entry in the focus charting method.
Which of the following is an example of an evaluation entry in the focus charting method?
It is an example of an action entry, not an evaluation entry. Action entries reflect the planning and implementation phase of the nursing process and include immediate and future nursing actions.
It is an example of a data entry, not an evaluation entry. Data entries reflect the assessment phase of the nursing process and include subjective and objective information about the client’s health status.
It is an example of a focus, not an evaluation entry. A focus is a key word or phrase that identifies the client’s concern, problem, or strength. It can be derived from a nursing diagnosis, a sign or symptom, an acute change in condition, a significant event, or a standard of care.
This is an example of an evaluation entry in the focus charting method because it describes the client’s response to the nursing intervention of teaching relaxation techniques. Evaluation entries reflect the evaluation phase of the nursing process and show whether the client’s goals and outcomes have been met or not.
it is an example of an action entry, not an evaluation entry. Action entries reflect the planning and implementation phase of the nursing process and include immediate and future nursing actions.
“I feel more calm and relaxed after practicing the breathing exercises.”
This is an example of an evaluation entry in the focus charting method because it describes the client’s response to the nursing intervention of teaching relaxation techniques. Evaluation entries reflect the evaluation phase of the nursing process and show whether the client’s goals and outcomes have been met or not.
Choice A is wrong because it is an example of an action entry, not an evaluation entry. Action entries reflect the planning and implementation phase of the nursing process and include immediate and future nursing actions.
Choice B is wrong because it is an example of a data entry, not an evaluation entry. Data entries reflect the assessment phase of the nursing process and include subjective and objective information about the client’s health status.
Choice C is wrong because it is an example of a focus, not an evaluation entry. A focus is a key word or phrase that identifies the client’s concern, problem, or strength. It can be derived from a nursing diagnosis, a sign or symptom, an acute change in condition, a significant event, or a standard of care.
Choice E is wrong because it is an example of an action entry, not an evaluation entry. Action entries reflect the planning and implementation phase of the nursing process and include immediate and future nursing actions.
Focus charting is a method for organizing health information in the client’s record using nursing terminology to describe the client’s health status and nursing actions.
It uses three columns: date and hour, focus, and progress notes. The progress notes are organized into data, action, and response (DAR).
Normal ranges for vital signs are:.
• Temperature: 36.5°C to 37.5°C (97.7°F to 99.5°F).
• Pulse: 60 to 100 beats per minute.
• Respirations: 12 to 20 breaths per minute.
• Blood pressure: 120/80 mmHg (systolic/diastolic).