Sample Dar Charting 4z3g3d

SAMPLE DAR CHARTING: DELIVERY ROOM 12/13/11 FOCUS: First stage of Labor in progress 1 PM D: Into labor room a 26 year old female, with chief complaints of lumbosacral pain characterized as mild to moderate, occurring irregularly and relieved by walking. G1Po, 40th weeks AOG. T-36.6 C, PR-78, RR-18, BP- 100/70. Uterine contractions occurring every 3-5 minutes of 30 seconds to 1 minute duration. Mild to moderate discomfort. 1:30 PM, IE done by__________ revealed 60% effacement, 4 cms dilatation. Station-1. 1:35 PM, IVF of D5LRS 1 Liter x 30 gtts inserted by _____________. ______________________________ Initials A: Vital signs taken and recorded, monitored uterine contractions, changed patient's clothes to patient's gown. Assisted with IE and IVF insertion and regulated to prescribed rate, perineal care done, 2 PM, Buscopan 1 tablet every hour started. DBE demonstrated. Instructed client to walk around the room. R: "Tumitindi ang sakit ng tiyan ko." DBE done by patient when in pain. ______________ Initals 4PM FOCUS: Second and Third Labor D: Into DR per stretcher with ongoing IVF of _______ at ________ ml level. "Tulo9y tuloy na ang sakit." 4:05 pm, IE done by ____________ revealed station-_______, _____% effacement, fully dilated. Uterine contractions occurring every minute, duration- 55 seconds, interval-5 seconds. PErineal bulging noted. With bloody show. BP-130/90, PR-90, RR-22. 4:15 pm, RMLE done by Dr. ______________, 4:16 pm, born an alive baby boy via SVD attened by _______________, assisted by _____________. 4:17 pm, Phenergan ____ ml given per IV by _____________. Wiping of baby dry by ___________, positioned newborn on mother's abdomen and breastfeedinginitiated by RN ___________. 4:19 pm, placenta out by ____________ mechanism, complete. Evacuation of uterine blood clots done followed by episiorrhaphy. _______________ Initials A: 4:07 pm transffered and brought to the DR. Positioned patient on DR bed, straps applied. Monitores vital signs. Coaching of patient done. Kept newborn on mother's chest warm by ___________. Application of perineal pads after perineal care done. Newborn taken by RN __________, transferred patient to stretcher. 4:23 pm, towards with student nurse _____________. _____________Initials