Vital signs, lab results, resident behavior.
What is Objective DATA?
What is CLEAR AND CONCISE nursing documentation?
A resident states, "I can't catch my breath" or rates their pain as a 5 on a scale from 0 to 10.
What is Subjective DATA?
Your nursing note is written in the D.A.R.P. format shortly after working with your resident.
What is COMPLETE AND TIMELY nursing documentation?
Resident positioned in high Fowler's position.
What is a nursing ACTION/intervention?
This information describes the "situation" (not Mike but the resident situation)...
What are Subjective and Objective DATA?
Repositioning a resident, administering oxygen or medication per MD orders, discharge teaching...
What are nursing ACTIONs/interventions?
Resident's respiratory rate has decreased to 16 and effort is now unlabored.
What is a patient RESPONSE/outcome?
Resident states " I can breathe easier now" or resident states their pain level has increased to an 8 out of 10.
What is a resident’s RESPONSE?
DATA: subjective and objective
ACTION: nursing interventions
RESPONSE: resident response/outcome
PLAN: future nursing action
What is the nursing documentation format known as D.A.R.P. ?
Resident stated his pain has decreased to a 3 on a scale from 0 to 10.
What is a resident RESPONSE/outcome?