SAMPLE DAR CHARTING

Date/TimeFocus

Nurse's Notes

31/5/2010 pre-operative care >Received asleep lying on bed with ongoing 5th IVF of PLRS iL+1 amp vit.b and vit.C x 16 hoursat 150 cc level infusing well at the right cephalic vein. D>With intact and patent CTT at 5th left intercostal space connected to thorabottle draining to yellowish secretion. No signs of respiratory distress. No compliants as of this moment. A> Established rapport. Assessed for signs and symptoms of respiratory distress.Checked presence of dentures,nail polish, and jewelries.Dentures removed and handed to watcher.Consent signed for Cholecystectomy attached to chart.Instructed on NPO.Oral care done. Shaving done. Skin prep done and clothing changed to O.R gown.Advised to do deep breathing exercises. Encouraged to verbalize feelings and concerns to upcoming procedure. 1:00 a.m >Above IVF consumed and replaced withthe 6th IVF of D5LRS 1L regulated to 28gtts/min. R>Pt. was able to show readiness to upcoming operation.Endorsed with an ongoing 6th IVF of D5LRS iL x 28 gtts/min at 650 cc level and scheduled for cholecystectomy at 8 a.m.

SAMPLE DAR CHARTING Date/TimeFocus

31/5/2010 Focus:mild pain

Nurse's Notes
>Received lying on bed with ongoing 1st IVF of PNSS iL+2 amps.vit B and vit.C x 16 at 360 cclevel infusing well at left metacarpal vein. D>With O2 inhalation at 2-4 LPM via nasal cannula.Poor skin nturgor noted. "nasakit ti takeb ko karkaru nu agkutikuti ak" as verbalized. Pain is rated as 4/10 and is localized on the anterior chest. Characterized as pricking pain.Facial grimaces and guarding behaviors noted when in pain. A> Established rapport. Assessed pain level and characteristic.Assessed skin turgor. Cutaneous stimulation done. Provided quiet and calm environment.Positioned to comfort. Encouraged verbalization of feelings.

5:20pm

>above IVF consumed and 2nd IVF of PNSS il x 16 hours replaced. R>Pt. verbalized that pain is reduced from 4/10 to 2/10.

11:00pm

>Endorsed with ongoing 2nd IVF of PNSS iLx16 at 800 cc level.

SAMPLE DAR CHARTING

Date/TimeFocus

Nurse's Notes

5/31/2010Focus:elevated body >Received awake in a semi-fowler's position 7:00 am temperature with ongoing IVF of D5NSS il x8 at 950 cc level infusing well at right cephalic vein arm. D>with intact and patent IFC connected to urine bag draining to light yellow urine. >"napudot ti riknak"as verbalized.With body temperature of 38.2oC per axilla.With flushed face and skin warm to touch. A>Assessed patency of IFC.Assessed for signs of fever.TSB continuously done.Offered fluids available at bedside. Removed extra clothings and blankets. Opened windows to enhance ventilation. Emphasized importance of increasing fluid intake.Encouraged verbalization of feelings and concerns. 2:30pm >Above IVF consumed and removed as ordered. R>Temperature lowered from 38.2oC to 37oC.