Sample of Focus DAR Charting

D= Data A= Action R= Response

Date Time Focus

6/23/21 9:00 am Incised wound RLQ D: Scant amount serous drainage on dressing, wound
borders pink, no odor present, denies discomfort
except with direct palpation of surrounding __signed
tissue. _____________________________ ____signed
9: 10 am A: NS irrigation as ordered. Sterile wet dressing applied.
Secured with adhesive----------------------------------signed
2:00pm R: Wound clean, no drainage present.___________signed
Signed: Alysa Atilano, SN Mary ann F. Rubio, RN Joan S.UY, RN

6/23/21 10: 00 am Pain L foot D: Reports wound dull/ throbbing ache L foot 4/10 – no
Radiation. Muscles appears tense, restless in bed.__signed
A: Assisted patient in a comfortable position. Mefenamic acid
500mg 1 cap given P.O________________________signed
10: 30 am R: Report’s pain relieved 0/10. Appears relaxed._____signed
Signed Alamia Hassan, SN Mary ann F. Rubio, RN Joan S. Uy,RN

6/23/21 9:00pm Gastric distress D: Awakened from light sleep by “indigestion / burning
Sensation.” Places hand over epigastric area. ___signed
Skin warm, dry, color pink, vital signs unchanged. ___signed
A. Given Maalox 30ml PO. Head of bed elevated ____signed
approximately 15 degrees. ____________________signed
9:30pm R: Report’s pain is relieved. Appears relaxed, resting quietly.

Signed Macy lee D. Abella,SN Mary ann F. Rubio, Rn Joan S. Uy RN