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State of Connecticut Technical High School System- Adult Education
Date: September 2012
Subject: Fundamentals of Nursing,
Documentation, Lesson 3, Focus Charting
Grade: Adult Education, LPN
Class: Licensed Practical Nurse
Teacher: Henrietta Simmons, RN.
Grading Questions for Lesson Plan Development
1. What are the important outcomes I want all students to learn as a result of this lesson?
2. What background knowledge/skills do students need to have to successfully master the lesson content?
3. What types of learning strategies, skills and modifications (reading, note taking, highlighting as you read,
writing, listening, etc.) do students need to use to successfully participate in this lesson AND where in the
lesson will the specific strategy be taught or reviewed?
4. What types of activities will I incorporate in my explicit direct teaching (modeling, small groups,
brainstorming, activating prior knowledge, problem solving, etc.) to assure that ALL students’
needs/interests/talents are met?
5. What are effective and appropriate ways (oral presentations, tests, reports, graphs, etc.) to evaluate how
well students learned the objective?
LESSON PLAN
Learning Objectives: the student will:
1. Discuss the LPN's responsibility in nursing documentation using Focus charting the DAR
charting format.
2. Identify the principles, key terms, approved abbreviations and symbols necessary for Focus
documentation.
3. Define DAR charting components , and provide an example of each.
*Required for each lesson
** Dependent upon learning sequence within the unit
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4. Discuss the elements of the nursing report and the process of critical thinking for the
corresponding actions and documentation of the nurse should take.
References to Curriculum Goal(s) and Corresponding Learner Outcome (e.g., Goal I, L.O. 1.2):
Fundamentals of Nursing, Section III, B. Documentation, Purpose, Components, and Principles.
Goals; Nursing skills of the LPN, Goals 11 and 16.
*Schema Activator (activity designed to stimulate the student’s interest and independent thinking
about the learning topic; activates prior knowledge):
My plan begin the class playing the virtual clinical excursions video, from Potter’s , Virtual Clinical
Excursions for Basic Nursing, section for chapter 7, patient David Ruskin, Room 303.
Students will observe video taking notes, and filling in the blank hospital note on page 35 of their work
book.
** Explicit/Direct Teaching Strategies:
1. Discuss of the make- up of a DAR note.
2. Use the link below for presentation.
http://prezi.com/_xogp6h1ehv7/nursing-documentation-using-dar-format/
3. Class discussion comparing the SOAP note with the DAR note
4.
Review with students Rubric being implemented for assessment of nursing notes. Rubric is
the last page of this lesson plan, a copy will be on the student information board.
** Practice Activity
1.
The students will read on the screen a SOAP note written on David Ruskin. The challenge is
to rewrite the SOAP note as a DAR note. Volunteers will read their DAR note to the class.
2.
The groups of three students will choose a number 1-9. The number correlates with a case
situation the students will write in both SOAP form and DAR format.
Application/ Assessment:
1 Students’ participation in the Virtual Clinical Excursion.
2. Students’ questions and answers throughout classroom discussions
*Required for each lesson
** Dependent upon learning sequence within the unit
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3. Practice of writing a DAR note following instructions form workbook.
4. Students performance on Fundamentals of Nursing course test in November.
5. Students adhering to documentation guidelines during their performance at the assigned clinical sites.
*Closure:
Statements from the students, the difference between the SOAP note and the DAR note.
Reminder to students; to read cases scenario # 41 & 42, page 38, in their workbook and write the
answers, as directed.
Resources and Technology used for this lesson:
Nursing Documentation Training | eHow.com http://www.ehow.com/facts_7464222_nursingdocumentation-training.html#ixzz1xtCjM9tx
http://www.makebeliefscomix.com/Story-Ideas/
http://prezi.com/_xogp6h1ehv7/nursing-documentation-using-dar-format/
References:
Burton, M., and Ludwig, L., (2011) Fundamentals of Nursing Care: Concepts, Connections & Skills,
F. A. Davis Company, Philadelphia, PA. Chapter 5 (pp. 79-114).
Burton, M., and Ludwig, L., (2011) Study Guide of Fundamentals of Nursing Care: Concepts,
Connections & Skills, F.A. Davis Company, Philadelphia, PA. Chapter 5 (pp. 33-48).
Potter, P., (2008) Virtual Clinical Excursions for Basic Nursing, (5th Ed.)Mosby, St. Louis Missouri,
Documentation Principles, Chapter 7 (pp.79-89)
Rosdahl, C., and Kowalski, M., (2012) Textbook of Basic Nursing, (10th ed.), Wolters, Kluwer Health,
Lippincott, Williams & Wilkins, Philadelphia, PA., Documentation and Reporting, Chapter 37, (pp. 414426).
*Required for each lesson
** Dependent upon learning sequence within the unit
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Rubric for assessment of student’s narrative nursing notes.
Correct identification of medical
abbreviations
Accurately distinguishes between
subjective and objective data
Beginning
Developing
Accomplished
Exemplary
1
2
3
4
Description of medical
abbreviations are at8089% and mastery of
performance., could be
attainable prior to the
final exam for the
entire course
Description of medical Medical abbreviations
are 100%correctly
abbreviations are
identified flecting the
90% identified
highest level of
correctly
performance.
Description of the
medical abbreviations
are less than 80%
correctly identified , it
is advisable for student
to seek extra
assistance.
Des subjective and
objective data are
correctly used and
placed properly in
SOAP note less than
80% in each exercise
reflecting a beginning
level of performance.
Description of
subjective and
objective data are
correctly used and
placed properly in
SOAP note 80-89% in
each exercise
description of
characteristics
reflecting development
and movement toward
mastery of
performance.
Description of
subjective and
objective data are
correctly used and
placed properly in
SOAP note 90% in each
exercise, student
performance is
meeting the standards
for clinical
performance
Description of
subjective and
objective data are
correctly used and
placed properly in
SOAP note 100% in
each exercise..
Description of
iactual written SOAP
note reflects less than
Formulates a clear and accurate all four components of
patient documentation using SOAP SOAP note with correct
format
use of medical
abbreviations with
more than four errors
errors in spelling /
abbreviations
reflecting performance
characteristics
reflecting a beginning
level of performance.
Below accepted
standards. Student is
required to meet with
instructor.
Description of actual
written SOAP note
reflects all four
components of SOAP
note with correct use
of medical
abbreviations and no
more than four errors
in spelling or medical
abbreviations
reflecting reflecting
development and
movement toward
mastery of
performance.
*Required for each lesson
** Dependent upon learning sequence within the unit
Description of
actual written SOAP
note reflects all four
components of SOAP
note with correct use
of medical
abbreviations and no
more than two errors
in spelling reflecting
reflecting mastery of
performance.
Description of actual
written SOAP note
reflects all four
components of SOAP
note with correct use
of medical
abbreviations and no
errors in spelling
reflecting the highest
level of performance.
Score
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*Required for each lesson
** Dependent upon learning sequence within the unit