Between rising acuity and the growing risk of lawsuits, it has never been more important that assisted living providers adhere to sound documentation practices. While there are many approaches to documentation, it is important that your records paint a complete picture of the event being recorded. For example, if a resident falls, it is not enough to just document that the resident fell. You should also documentation the actions taken and the ultimate outcome. Simply documenting, “Resident fell” without information about the first aid provided, calling 911, the resident being transported to the hospital, notifying the physician and family, etc, makes it look like nothing was done about the fall.
There are many methods and formats for creating a narrative entry but we recommend the “DAR” format. If every entry follows this format you will be on the right track to complete and accurate narrative charting.
- DataThe “D” in “DAR” refers to data. In this section of your narrative entry you will provide data about the situation. Such as the date and time, what happened, vital signs, pain status, etc.EXAMPLE:
8/11/08 7:45 am Entered Jane’s room and found her on the floor next to her bed. Jane stated “I don’t remember what happened, but I think I feel down, please help me up.” Resident reported significant pain on the right side of her chest when attempting to move. Small amount of blood identified on right side of head just above her right ear.
- ActionThe “A” in the “DAR” charting format refers to action. What did you do? What action did you take in response to the data already described?A narrative entry is never complete without an explanation of the action you take. Imagine if the narrative entry example stopped after the data entered above; the entry would not paint a complete picture of the situation and how you handled it. Remember…if it wasn’t documented, it wasn’t done.
Instructed resident to remain on the floor and radioed for assistance from another caregiver. Caregiver John Doe entered the room and I asked him to call 9-1-1. I remained with resident, told her the paramedics would arrive soon.
- ResponseThe final step in a “DAR” narrative entry is the “R”, which stands for response. How did the resident respond to the actions you took?You may need to enter two responses, one immediately and then another as a follow up.
8/11/08 8:15 am Paramedics arrived and transported resident to St. Mary’s Hospital.
8/11/08 1:30 pm Spoke to doctor James Doe from St. Mary’s Hospital. She informed me that Jane has two broken ribs and will be staying in the hospital overnight.
Whether you follow “DAR” or another documentation format, it is important the goals of a complete and accurate record is achieved. Click here to learn more about our Documentation staff training DVD and how it can help you educate your staff on this important issue.