The method of case documentation in nursing that uses data, action, and response in the narrative is called

Appeared in: GMCH - 2015

Explanation

Focus charting is a patient-centered documentation system.
It uses a narrative format known as DAR: Data, Action, and Response.
The 'focus' can be a patient's problem, strength, concern, or a significant event.
Data (D) includes subjective and objective assessment findings.
Action (A) details the nursing interventions and treatments provided.
Response (R) describes the patient's outcome or reaction to the interventions.

Option B: The Case Management Model focuses on managing care using critical pathways and standardized care plans to achieve outcomes within a specific timeframe. It documents variances from the pathway, not using a DAR format.
Option C: The Problem-Oriented Medical Record (POMR) is organized by the patient's problems and famously uses the SOAP (Subjective, Objective, Assessment, Plan) or SOAPIER format for progress notes.
Option D: Charting by protocol involves documenting care that is delivered according to pre-established institutional protocols or standing orders. It doesn't follow a specific narrative structure like DAR.

Clinical Relevance

Nursing practice connection: Knowing Nursing Documentation Methods helps nurses interpret findings accurately and avoid errors in routine assessment, medication administration, and patient teaching.
Accurate and clear documentation is a legal requirement and a critical tool for ensuring continuity of care and communication among the healthcare team.
Understanding different charting methods is essential as nurses may work in various facilities that use different systems.
Focus charting helps in creating a more holistic view of the patient, moving beyond just their medical problems to include their strengths and concerns.

How to Approach the Question

First, identify the keywords in the question stem: 'data, action, and response'. This is a clear acronym.
Recall the different methods of nursing documentation and the acronyms or formats associated with them.
Match the given acronym (DAR) to the correct documentation method.
Focus Charting uses the DAR (Data, Action, Response) format.
Problem-Oriented Medical Record (POMR) uses the SOAP (Subjective, Objective, Assessment, Plan) format.
Eliminate the other options based on their known characteristics (e.g., Case Management uses critical pathways).

Concept Tested & Keywords

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E6 Nursing Fundamentals Taylor p. 108-110

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