Resident positioned in semi-Fowler' s position for comfort. Oxygen administered at 2L/min via nasal cannula. A: Writer promptly notified nursing staff and initiated vital sign assessment. Never use names, use “patient” “resident” “client” 3 examples D: Resident experienced sudden onset of chest pain and shortness of breath. Remember SHORT AND SWEET, charting is not an essay or story. Use examples of skills you have learned in lab, it doesn’t have to be all real, use your imagination. P: Will monitor every 1hr as resident is at risks for falls. R: Resident thanked writer and is resting comfortable watching tv. Remote control given to resident, side rails up and fall mat at side of bed as per care plan. D: Writer found resident trying to climb out of bed, resident stated” I need my remote control, how do you expect me to watch tv!!” A: Writer assisted resident back to bed, positioned in supine position. P: Will toilet resident before and after meals. R: Resident compliant and thankful to writer for helping. ![]() ![]() A: Writer preformed peri care, clean brief applied, bed linens changed. ![]() DARP Examples: D: Resident incontinent of large loose BM.
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