# Situation: A 36-year-old man with schizophrenia is on a psychiatric ward that uses an electronic health record (EHR). Nurses write focus charting notes, and the treatment team writes SOAPIE progress notes (Subjective, Objective, Assessment, Plan, Intervention, Evaluation). This morning he threw chairs in the dayroom and was placed in seclusion on the order of the attending psychiatrist. Later, after release, he becomes anxious, and a nurse writes this focus charting note: Focus: Anxiety Data: Pacing the hallway, wringing hands; says, "Something bad is going to happen." Action: Stayed with him in a quiet area; guided slow breathing for 5 minutes. Response: At 14:30 stopped pacing; said, "I feel a little better." Lorazepam 1 mg given orally at 14:35 as ordered. The charge nurse asks for one revision. Which revision is correct?

> source: MyMerci (mymerci.kr)  
> url: https://mymerci.kr/pages/nclex_q.php?qn_id=630255  
> language: ko  
> subject: Nursing Practice V — Care of Clients with Maladaptive Patterns of Behavior; Care of Clients with Life-Threatening Conditions, Acute Multi-Organ Problems, High Acuity and Emergency Situations

## 문제

Situation: A 36-year-old man with schizophrenia is on a psychiatric ward that uses an electronic health record (EHR). Nurses write focus charting notes, and the treatment team writes SOAPIE progress notes (Subjective, Objective, Assessment, Plan, Intervention, Evaluation). This morning he threw chairs in the dayroom and was placed in seclusion on the order of the attending psychiatrist.

Later, after release, he becomes anxious, and a nurse writes this focus charting note:
Focus: Anxiety
Data: Pacing the hallway, wringing hands; says, "Something bad is going to happen."
Action: Stayed with him in a quiet area; guided slow breathing for 5 minutes.
Response: At 14:30 stopped pacing; said, "I feel a little better." Lorazepam 1 mg given orally at 14:35 as ordered.
The charge nurse asks for one revision. Which revision is correct?

## 보기

1. Data should paraphrase his words instead of quoting them
2. The lorazepam belongs under action, with its own response **✔ 정답**
3. Response should not quote him, since quotes belong in data
4. Focus should be a full diagnostic statement with etiology

**정답: 2**

## 해설

In focus charting, the response describes how the client reacted to the actions. His stopping pacing and saying he feels better are correctly recorded as response, but the lorazepam given afterward is a new action; it belongs under action and needs its own response, such as his behavior after the drug took effect. The data and focus are written correctly.

## 심화 해설

Core concept: Focus charting (D.A.R.T.) structure

Focus charting organizes a note into four columns: Data, Action, Response, and sometimes Focus at the top. The Response column is reserved for the client’s reaction to the specific actions just documented. In this note, the client’s stopping pacing and stating he feels better are correctly placed under Response because they directly follow the nurse’s action of staying with him and guiding slow breathing [1].

However, lorazepam 1 mg given orally at 14:35 is not a client response. It is a nursing intervention — a new action. In focus charting, each action must be paired with its own response so the reader can see what happened after that intervention. Placing lorazepam inside the Response column mixes an intervention with client outcomes, which breaks the D.A.R.T. logic and makes it impossible to evaluate whether the medication was effective.

The correct revision is to move the lorazepam entry to the Action column, then document a separate Response describing the client’s behavior after the drug took effect — for example, reduced anxiety, decreased pacing, or sedation level at a later time.

Watch out! The Response column answers “What happened after the action?” — not “What did the nurse do next?” A medication given is always an Action, never a Response.

Key point! The Data column may include direct quotes from the client, and the Focus may be a simple problem label such as “Anxiety.” Neither of those elements requires revision in this note.

| Column | What belongs there | Example from this note |
| --- | --- | --- |
| Focus | Problem or nursing concern, brief label | Anxiety |
| Data | Subjective and objective cues, including direct quotes | Pacing, wringing hands, “Something bad is going to happen.” |
| Action | Nursing interventions performed | Stayed with him, guided slow breathing, gave lorazepam 1 mg PO |
| Response | Client’s reaction to each action | Stopped pacing, “I feel a little better” (after breathing); later response after lorazepam |

The D.A.R.T. framework is designed to make documentation efficient and usable across disciplines. When each action has a clearly linked response, the record supports continuity of care and allows the treatment team to evaluate whether interventions are working [1]. A note that buries a new medication inside the Response column obscures that evaluation and can create legal ambiguity about what was done and what resulted .References (research sources)

- [1]Nursing Documentation Interface Configuration Based on Demand Assessment for AI System Development.Research articleHsieh CY, Liao PH, Wu MW (2025) · DOI: 10.3233/SHTI251326

## 임상 시나리오

Focus Charting (DAR) DocumentationSeparating Actions from Responses
In focus charting, the Response column is reserved for the client's reaction to a specific Action. A medication given, such as lorazepam 1 mg PO, is always an Action, never a Response.

Each Action must be paired with its own Response. Document the client's behavior after the drug takes effect—such as reduced anxiety, decreased pacing, or sedation level—at a later time.

CautionPlacing an intervention inside the Response column breaks the DAR logic and makes it impossible to evaluate whether the medication was effective. The Response column answers "What happened after the action?"—not "What did the nurse do next?"

## 핵심 개념

- **Focus Charting** — A documentation method using columns for Data, Action, and Response (DAR) to organize client-centered notes around a specific focus or problem.
- **Response (in DAR)** — The client's reaction or outcome following a specific nursing action; it evaluates the effectiveness of that intervention.
- **Action (in DAR)** — Nursing interventions performed, including medication administration, therapeutic communication, or physical care.
- **Data (in DAR)** — Subjective and objective information collected about the client, which may include direct quotes from the client.
- **SOAPIE** — An alternative progress note format used by interdisciplinary teams: Subjective, Objective, Assessment, Plan, Intervention, Evaluation.

## 같은 주제 문제

- [Situation: A 45-year-old woman with bipolar I disorder, current episode manic, is on the a…](https://mymerci.kr/pages/nclex_q.php?qn_id=630051)
- [Situation: A 45-year-old woman with bipolar I disorder, current episode manic, is on the a…](https://mymerci.kr/pages/nclex_q.php?qn_id=630052)
- [Situation: A 45-year-old woman with bipolar I disorder, current episode manic, is on the a…](https://mymerci.kr/pages/nclex_q.php?qn_id=630053)
- [Situation: A 45-year-old woman with bipolar I disorder, current episode manic, is on the a…](https://mymerci.kr/pages/nclex_q.php?qn_id=630054)
- [Situation: A 45-year-old woman with bipolar I disorder, current episode manic, is on the a…](https://mymerci.kr/pages/nclex_q.php?qn_id=630055)
- [Situation: A 24-year-old man with schizophrenia is in his second week on a psychiatric war…](https://mymerci.kr/pages/nclex_q.php?qn_id=630151)
- [Situation: A 24-year-old man with schizophrenia is in his second week on a psychiatric war…](https://mymerci.kr/pages/nclex_q.php?qn_id=630152)
- [Situation: A 24-year-old man with schizophrenia is in his second week on a psychiatric war…](https://mymerci.kr/pages/nclex_q.php?qn_id=630153)

---

More free questions: [기출문제](https://mymerci.kr/)

_학습 참고용입니다. 실제 임상은 최신 지침과 소속 기관 프로토콜을 따르세요._