Professional Documents
Culture Documents
It is a
method of organizing health information in an individuals record. Focus Charting is a systematic approach to
documentation.
The progress notes are organized into (D) data, (A) action, and (R) response, referred to as DAR (third column).
The data category is like the assessment phase of the nursing process. It is in this category that you
would be writing your assessment cues like: vital signs, behaviors, and other observations noticed from
the patient. Both subjective and objective data are recorded in the data category.
The action category reflects the planning and implementation phase of the nursing prosess and includes immediate
and future nursing actions. It may also include any changes to the plan of care.
The Response Category
The response category reflects the evaluation phase of the nursing process and describes the clients response to
any nursing and medical care.
Pain
The focus of this problem is pain. Notice the way the D,A,R were written.
>Encouraged deep
breathingexercises and relaxation
techniques
R:
Hyperthermia
R:
10:00pm>Temperature decreased
from 38.9 to 37.1 OC
Another Variation
This is DAR made by Jay-D Man of Slideshare.net. with some modifications made. This is a very good variation.
F2: Hyperthermia
F3: Fatigue
A: 9:00am
M advised SO to give the ff. meds at the right time, dose, frequency and route
E encouraged to maintain cleanliness of the house and surroundings
T advised to go to follow-up consultations on the prescribed date
H encouraged to do chest tapping to facilitate mobilization of secretion
O observed for signs of super infections such as fever, black fury tongue and foul odor discharges
D encouraged to eat fresh vegetables and fish
S advised to continue praying to God and hear mass on Sunday
For us health care workers, to effectively communicate either through oral communication and documentation, we
should be knowledgeable about the different abbreviations and acronyms.
The following is a short list of the different abbreviations and acronyms the health-care industry have:
A /G = albumin/globulin ratio
AAL = anterior Axillary Line
ABG = arterial blood gases
AC = before eating
ACE = angiotensin converting enzyme
ACL = Anterior Cruciate Ligament
ACLS = advanced cardiac life support
ACTH = adrenocorticotropic hormone
ADH = anti-diuretic hormone
ADL = activities of daily living
ADSF = Anterior Decomposition Spinal Fusion
AFB = acid-fast bacilli
AFP = alpha-fetoprotein
AGA = appropriate for gestational age
AGN = Acute Glomerulonephritis
AI = aortic insufficiency
AIDS = acquired immune deficiency syndrome
AKA = Above Knee Amputation
AKA = above knee amputation
ALD = alcoholic liver disease
ALL = acute lymphocytic leukemia
ALP = alkaline phosphatase
ALT = alanine transaminase, alanine aminotransferase
APR = Abdominoperineal Resection
ARF = Acute Renal Failure
ASA = Acute Surgical Abdomen
ATN = acute tubular necrosis
AU = both ears
AV = atrioventricular
ad lib = as much as needed
c = with
C/O = complaining of
CA = calcium, cancer, carcinoma
CAA = crystalline amino acids
CABG = coronary artery bypass graft
CAD = coronary artery disease
CAPD = continuous ambulatory peritoneal dialysis
CAT = computerized axial tomography
CA = Cancer
CBC = complete blood count
CBD = common bile duct
CBDE = Common Bile Duct Exploration
CBD = Common Bile Duct
CBG = capillary blood gas
CBI = continuous bladder irrigation
CBS = capillary blood sugar
CC = chief complaint
CCK = cholecystokinin
CCPD = continuous cyclic peritoneal dialysis
CCU = clean catch urine or cardiac care unit
CCV = critical closing volume
CF = cystic fibrosis
CHF = congestive heart failure
CHO = carbohydrate
CI = cardiac index
CKD = Chronic Kidney Disease
CLEA = Continuous Lumbar Epidural Anesthesia
CLT = Clinical Laboratory Technician
CML = chronic myelogenous leukemia
CN = cranial nerves
CNS = central nervous system
CO = cardiac output
COM Chronic Otitis Media
COPD = chronic obstructive pulmonary disease
CP = chest pain, cleft palate
CPD = cephalo-pelvic disproportion
CPK = creatinine phosphokinase
CPP = cerebral perfusion pressure
CPR = cardiopulmonary resuscitation
CRCL = creatinine clearance
CRF = chronic renal failure
CRT = capillary refill time
CSF = cerebrospinal fluid
CT = computerized tomography
CVA = cerebral vascular accident, costovertebral angle
CVP = central venous pressure
D3 = Distal Third
D5W = 5% dextrose in water
DAT = diet as tolerated
DC = (dc) discontinue
DIC = disseminated intravascular coagulopathy
DIH = Direct Induinal Hernia
DKA = diabetic ketoacidosis
DL = Direct Laryngoscopy
DM = diabetes mellitus
DNA = deoxyribonucleic acid
DNR = do not resuscitate
DOA = dead on arrival
DOE = dyspnea on exertion
DPT = diphtheria, pertussis, tetanus
DTR = deep tendon reflexes
DVT = deep venous thrombosis
DX = diagnosis
GB = gallbladder
GC = gonorrhea
GCS = Glascow Coma Scale
GERD = gastroesophageal reflux disease
GETA = General Endotracheal Anesthesia
GFR = glomerular filtration rate
GI = gastrointestinal
GSW = Gunshot Wound
GTT = glucose tolerance test
GU = genitourinary
HB = hemoglobin
HBP = high blood pressure
HCG = human chorionic gonadotropin
HCO3 = bicarbonate
HCT = hematocrit
HD = hemodialysis
HDL = high density lipoprotein
HEENT = head, eyes, ears, nose, throat
HPT = Hemoperitoneum