Nurses Notes: DART Format
Nurses notes come in different types depending on the facility you work for or school you are studying in. Nurses notes are one of the biggest problems nursing students have many are insure exactly what needs to be placed into their notes.
The DART format is closely related to the DAR format and SOAP(ER) Formats. When using the DART format you will mostly likely be using it when doing Focus Charting. The DART Format is simple, effective, easy to follow and read. The DAR format is the same as the DART format the only difference is there is one more step to DART making it a more rounded style in nurses notes.
Data: Under data you will include all your patients' subjective and objective information. Under data you will include all observations you have made, specific times, your data should support the patient's problem.
• Subjective data: is based on what the patients has told you and explained to you about their condition. Subjective data is all the information collected during verbal statements this type of data is not data collected during physical examination.
• Objective data: This is data you have collected during your head to toe assessment or during your focal assessments. Objective data also includes vital signs and physical findings on the patient's body.
Action: Action involves all the care you have administered to your patient. Anything you have done to provide care to the patients is considered actions such as passing meds or wound care. You will include any changes you have made.
Response: Response requires you to chart any response to care you have administrated under the action. You will chart about effective and ineffective treatments. For example if you administered pain medication and a patient complains they are not helping you would chart that the pain medication was ineffective and if you contacted the patient's doctor. If a treatment was effective you will chart the procedure and the outcome.
Teaching: Patient teaching is very important if you have used patient teaching you will chart what methods you have used and any materials you may have shared with the patient.
A nurse's note is considered a legal document and should always be carried out in a professional way. Nurses notes are only to contain information that is factual they must not contain any personal opinions. One of the most important things to remember is that if a nurse does not chart the care she has given then it is considered to mean that it did not happen.