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SAMPLE DAR CHARTING: DELIVERY ROOM12/13/11

 FOCUS: First stag !" La#!r i$ %r!grss 

1 PM D: Into labor room a 26 year old female, with chief complaints of lumbosacral paincharacterized as mild to moderate,occurring irregularly and relieed by wal!ing" 

#1Po, $%th wee!s &'#" ()*6"6 +, P)-., )1., /P) 1%%0-%" terine contractions occurringeery *) minutes of *%seconds to 1 minute duration" Mild to moderate discomfort" 1:*% PM,I3 done by4444444444 reealed 6%5 effacement, $cms dilatation" tation)1" 1:* PM, I78of D9 1 9iter *% gtts inserted by 4444444444444"

 

 444444444444444444444444444444 Initials &: 7ital signs ta!en and recorded, monitored uterine contractions, changedpatient;s clothes to patient;s gown" &ssisted with I3 and I78 insertion andregulated to prescribed rate, perineal care done, 2 PM, /uscopan 1 tablet eery hour started"D/3 demonstrated" Instructed client to wal! around the room" : <(umitindi ang sa!it ngtiyan !o"< D/3 done by patient when in pain" 44444444444444 Initals$PM

8'+: econd and (hird 9aborD: Into D per stretcher with ongoing I78 of 4444444 at 44444444 ml leel" <(ulo=y tuloy naang sa!it"< $:% pm, I3 done  by 444444444444 reealed station)4444444, 444445effacement, fully dilated" terine contractions occurring eery minute,duration) seconds,interal) seconds" P3rineal bulging noted" >ith bloody show" /P)1*%0=%, P)=%, )22"$:1 pm, M93 done by Dr" 44444444444444, $:16 pm, born an alie baby boy ia 7Dattended by 444444444444444, assisted by 4444444444444" $:1- pm,Phenergan 4444 ml gien per I7 by 4444444444444">iping of baby dry by

 44444444444, positioned newborn on mother;s abdomen and breastfeeding initiated by? 44444444444" $:1= pm, placenta out by 444444444444mechanism, complete" 3acuation of uterine blood clots done 

followed by episiorrhaphy" 444444444444444 Initials &: $:%- pm transffered and

brought to the D" Positioned patient on D bed, straps applied" Monitoredital signs" +oaching of patient done" @ept newborn on mother;s chest warm by

 44444444444" &pplication of perineal pads after perineal care done" ?ewborn ta!en by ? 4444444444, transferred patient to stretcher" $:2* pm, towards with student nurse 

 4444444444444" 4444444444444Initials

LABOR ROOM SOAP CHARTING

(TIME)>Into LR, a __ y/o G__P__ mother from _____ ward, per _____ accompanied by _____, withonoin I!" of _______ at ____ cc #e$e#, inf%&inwe## on ____ hand'> *+> ith Pain rated a& -.0, ara$atedby ________, characteri1ed a& _______,radiatin to _______, occ%rrin _______'2>ith !ita# in&3 T4P4R45P4'> Irritabi#ity noted'> Pacin mo$ement& noted'> -arrowed foc%&'> Moanin/Grimacin noted'> ith "6T of ___beat& per min%te at _____'> 7terine contraction& occ%rrin e$ery ___

min with d%ration of ___ &ec/min'8> Labor pain& re#ated to %terinecontraction& &econdary to #abor prore&&ionP>Monitor !>8&&e&& pain P9RT>8&&i&ted on amb%#ation(TIME)> 6-55 i$en $ia I! p%&h by -2:'> In&tr%cted on3 a' :5E b' ;%attin> Reinforced -P2 a& ordered> Enco%raed $erba#i1ation of fee#in&of an<iety/pain'(TIME)> 5ro%ht to :R tab#e amb%#atory/per

NURSES NOTESF DAR (MOTHER)

F-Safe deliveryA case of INITIAL NAME, AGE, CIVIL STATUS,OB HISTO! fro"

A##ESS $as ad"i%%ed %o VSMMC d&e %o 'ai()eleva%ed *lood 'ress&re,

*reec+ 'rese(%a%io(, cord 'rola'sed, e%c No%e. a''lica*le o(ly if %+e '% is

direc% %o #

# -/ri"ace face (o%ed, $i%+ s%ro(/ &%eri(e co(%rac%io(s (o%ed, $i%+

f&lly effaced a(d dila%ed cervi0 &'o( i(%er(al e0a"i(a%io(, *&l/i(/ of

'eri(e&" (o%ed

A -Us+ered %o #elivery roo" via $+eelc+air1s%re%c+er, "o&(%ed %o

delivery %a*le, 're'ared '+ysically, e'isio%o"y do(e )o'%io(al, delivered

s'o(%a(eo&sly a( alive *a*y *oy1/irl a% TIME, 'lace(%a o&% i( Sc+&l%2e1

#&(ca( "ec+a(is" a% TIME, $i%+ %+e i(i%ial 'os%'ar%&" B3 of

 4444""+/, $i%+ 4444o0y%oci( i(f&sed %o 'rese(% IVF *y (&rse o( d&%y,e0'lora%io( for 'lace(%al fra/"e(%s do(e, re'air of 'eri(eal lacera%io(

do(e *y #r 1I(%er(1 3GI Fa"ily (a"e)o'%io(al,'os%'ar%&" care do(e

 - E(dorsed %o (&rse o( d&%y co(scio&s, $i%+ o(/oi(/ o0y%oci( dri',

fir"ed a(d co(%rac%ed &%er&s, $i%+ "i(i"al va/i(al *leedi(/

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8dmitted a ca&e of name, ae, &e<, GP from addre&&d%e to #aborpain&/premat%rer%pt%re of membrane&/ preec#amp&ia/ec#amp&ia/ &e$ere b#eedin/ intra%terinefeta#/ p#acenta pre$ia/ tran&it de#i$ery'"3 Labor pain&/8#tered comfort:3 rimaced face noted, =ept on ma&&ain her bac=,&tron re%#ar contraction& ob&er$ed, prof%&eper&piration noted, f%## cer$ica# di#atation and

eacement noted, increa&ed re&piration& noted'83 %&hered to de#i$ery room, mo%nted on the de#i$erytab#e, po&itioned in #ithotomy po&ition, perinea#preparation done, a&eptica##y p#aced #ein& andbaby?& recei$er on mother?& abdomen, coached on howto bear down proper#y, a&&i&ted re&identond%ty d%rin epi&iotomy, &%pported perine%m proper#y, de#i$ered an a#i$e babyender at time, de#i$ered thep#acenta in :%ncan/ch%#t1 mechani&m at time,a&&i&ted re&ident on d%ty on the man%a# e<p#oration of the%ter%&, po&tpart%m 5Pta=en3 readin (admi&teredMetherine amp IM a& ordered), p%t on a diaper

A NURSE’S PRAYER

Dear God, teach me to receive the sick in

Thy Name. Give to my efforts success for

theglory of Thy Holy Name. It is Thy

work; without Thee, I cannot succeed.

Grant that the sick Thou hast placed in

my care may be abundantly blessed, and

not one of them be lost because of any

neglect on my part. Help me to overcomeevery temporal weakness, and

strengthen in me whatever may enable

me to bring joy to the lives of those I

serve. Give me grace, for the sake of Thy

sick ones and of those lives thatwill be

influenced by them. AMEN

NURSE’S PRAYER

Lord ma=e me a $e&&e# of thy b#e&&in&'7&e me a& too# to ma=e the &ic= we##'

Grant me wi&dom that I may ma=e the rihtdeci&ion

on re&pondin to the need& of my patient&'Grant me patience that I may con&ider my

patient& reaction&a& con&e;%ence& of hi& i##ne&& and not

per&ona##y directed to me'Lihten my path that I may a#way& carry o%tmy re&pon&ibi#itie& accordin to yo%r wi##'

 That no harm &ha## be &et %pon me,my patient& and tho&e with whom I wor=

beca%&e of what i& #ac=in in me'2h Lord, &how me how to act in &%ch a way

that a## I do wi## be re@ection& of #o$e to other&and #a&t#y,

Lord, rant that I may a#way& remember to %&eyo%r ift