DAR documentation assignment instruction scenarios PDF

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NURS11325-Lab 1 Documentation Assignment Instruction: Clinical documentation is an important component within the practice of healthcare providers. Healthcare providers are required to make and keep records of their practice. They are accountable for ensuring that their documentation is accurate and meets the practice standards (CNO, 2008). “Documentation presents an accurate, clear and comprehensive picture of the client’s needs, the interventions and the client’s outcomes” (CNO, 2008, p. 6). In this assignment, use DAR format to make a * type-written clinical progress note on an observation/assessment that you made on a client’s condition/behaviour in a case scenario. Choose only one case scenario out of the following three scenarios. Use the progress note for documentation, which is provided along with this assignment instruction. Assessment data, planning/actions and evaluation should be comprehensive and clear providing adequate information about client’s needs, appropriate interventions and client’s outcomes. Refer to the documentation assignment rubric for specific evaluative criteria.

DAR ((Problem-oriented Approach on Documentation) D –Data Subjective and objective patient assessment date that supports the focus statement or describes observations of a significant event A- Action Immediate or future actions or plans of action or care based on the evaluation of assessment data R- Response The patient's response to the action taken. *Note: Progress note should always be hand-written as per the CNO’s standards; however, given the current situation with Covid_19 pandemics, the assignment is altered to be completed in a type-written format just for the purpose of the assignment. Students must be aware that the progress note is always to be hand-written according to the CNO’s standards.

W20 Sheridan

Scenario 1 – Fall You are assigned to Mrs. Jones for morning care. While assisting her with her morning bath you notice a purplish-blue bruise on her left hip. When you comment on it, she states that she fell yesterday when getting off the toilet, but didn’t tell anyone. She states the area is sore and moans when it is touched. Her mobility status stated on the care plan is Independent.  Complete a DAR note on your observations, assessments and actions, as well as possible client response. Consider the date and time being the date and time that you are currently working on this assignment.

Scenario 2 – Nutrition & Feeding At 0900, the residents at Collingwood Crossing LTC are brought into the central dining room for breakfast. Mr. Midgely is an 81-year-old gentleman with history of dementia, HTN, and type 2DM. He normally sits by himself at the corner table eating independently. Although over the last few months he has been having increased weakness, along with decreased mobility and needing more help with ADLs. You are assisting to feed another resident when you keep noticing Mr. Midgely falling asleep at the table, then waking up coughing his pocketed food. He is also sitting in a slouched position, with lots of food on his shirt/pants. You notify his nurse, who instructs you and another nursing student go over to check on Mr. Midgely.  Complete a DAR note on your observations, assessments and actions, as well as possible client response. Consider the date and time being the date and time that you are currently working on this assignment.

Scenario 3 – Therapeutic Communication Mr. Sherbino is a 76 year old who is in your LTC due to a recent stroke with left arm paralysis. He has been depressed with the recent changes in his life and is reluctant to get out of bed. Before dinner you ask him if he would like assistance to the wheelchair. He tells you that he doesn’t want to be a bother to anyone, and is upset that he no longer can do things independently. He agrees to get up to the wheelchair with your help. You note a red area to his left elbow and shoulder, he had turned onto the left side in the bed.  Complete a DAR note on your observations, assessments and actions, as well as possible client response. Consider the date and time being the date and time that you are currently working on this assignment.

W20 Sheridan...