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DARP Charting Student Example | Healthcare Documentation

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DARP charting student copy
Focus DARP
Focus:
D:
A:
R:
P:
Example:
Date /
Time
Dec. 25
0730
0745
0900
Focus
Pain
Pain
Pain
D: Resident guarding left elbow. Winced when elbow was touched. Resident
states pain is 4/10. ----------------------------------------- Signature, SN2, U of C
A: Ice pack applied to left elbow. ______________ Signature, SN2, U of C
R: Resident states pain is 1/10/. No longer guarding elbow.
__________________________________________ Signature,SN2, U of C
Decide if these statements are Focus, D, A, R, or P – Some might be more than one
“I can’t breathe”
Patient was contacted by phone at 1000.
Meeting scheduled for next Tuesday.
Infant latched well, mother stated “It doesn’t hurt.”
Client given number to Families Matter.
Temperature 35.6 degrees c.
Ambulance called.
Reassess oxygen saturation in 30 mins.
Client was walking on toes for entire morning program.
Will talk to mother about the pamphlet in one week.
Temperature increased to 36.7 degrees c.
Skin pink and dry.
Client started crying.
DARP charting student copy
Client will be weighed at next appointment to assess weight gain.
Client assisted to bathroom.
Mother stated she understood what the Best Beginning program offers.
Will provide client with food coupons weekly.
Parents accompanied children to play time.
Client home cluttered and garbage noted on floor.
Home support worker talked with client about symptoms of depression.
Edinburgh Postnatal Depression Scale (EPDS) score 8.
Client instructed to call family physician today.
Client stated that she “has never thought of suicide”
Following discussion with support worker, the client stated she “felt much better.”
Bed bath given.
Child youngest of 3 in the family.
Nurses’ Aides will ensure that client takes all medications. Bed area will be checked for medications
twice a day.
Client refuses medications.
Infant placed skin to skin on mother with one blanket and a hat.
Ages and Stages questionnaire completed.
Writer asked client why he is not taking medications.
Weight loss of 7% since yesterday.
Mother taught breastpumping and given handout with expected number of wet and dirty diapers for
day of age.
Will call tomorrow to assess infant output.
Following 20 mins of pumping, mother had 20 mls expressed breastmilk.
Client accepted food coupons.
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