# Situation: A 64-year-old woman with liver cirrhosis is admitted to the medical ward because of vomiting and increasing abdominal girth. The ward writes its nursing notes in focus charting and uses charting by exception on its assessment flow sheets. Its electronic health record keeps an audit trail that shows when each entry was written. In the focus charting format used on the ward, each note has three parts labeled D, A and R. What does the nurse record under R?

> source: MyMerci (mymerci.kr)  
> url: https://mymerci.kr/pages/nclex_q.php?qn_id=630356  
> language: ko  
> subject: Nursing Practice IV — Care of Clients with Problems in Nutrition and Gastrointestinal, Metabolism and Endocrine, Perception and Coordination

## 문제

Situation: A 64-year-old woman with liver cirrhosis is admitted to the medical ward because of vomiting and increasing abdominal girth. The ward writes its nursing notes in focus charting and uses charting by exception on its assessment flow sheets. Its electronic health record keeps an audit trail that shows when each entry was written.

In the focus charting format used on the ward, each note has three parts labeled D, A and R. What does the nurse record under R?

## 보기

1. The results of the laboratory tests done that day
2. The nurse's recommendation to the next shift's nurse
3. The client's response to the nursing action taken **✔ 정답**
4. The reason the focus of the note was chosen

**정답: 3**

## 해설

Focus charting (DAR) records Data, Action, and Response about a focus, which may be a client concern or strength, not only a problem. Response describes the client's reaction to the nurse's action, closing the loop of each note.

## 심화 해설

Understanding the DAR format

Focus charting organizes each note around a single focus, which can be a client concern, a change in condition, or even a strength. The note itself has three labeled parts: D for Data, A for Action, and R for Response.

The R component closes the loop of the nursing process within that single note. After the nurse documents objective and subjective findings under D and the interventions performed under A, the R section records how the client actually reacted to those nursing actions. For this patient with liver cirrhosis, an example would be documenting that after antiemetic administration and abdominal girth measurement, the vomiting subsided and the client reported less nausea.

Key point! The R is not a plan for the future, a recommendation to another nurse, or a summary of lab values. It is the evaluation of the client's response to the specific action just documented in that same note.

| DAR component | What it contains | Example for this patient |
| --- | --- | --- |
| D (Data) | Subjective and objective findings that support the focus | Client vomited twice this shift; abdominal girth increased from 92 cm to 96 cm |
| A (Action) | Nursing interventions performed | Administered prescribed antiemetic; repositioned to semi-Fowler's; measured abdominal girth |
| R (Response) | Client's reaction to the action taken | No further vomiting for 2 hours; client states nausea is reduced |

Watch out! Do not confuse the R in DAR with the R in SOAP charting. In SOAP, R stands for Revision or Response to treatment in some settings, but in focus charting, R consistently means the client's response to the nursing action documented under A.

The audit trail feature of the electronic health record mentioned in the scenario is relevant to documentation integrity, but it does not change what belongs under each DAR heading. Accurate documentation of the client's response is essential for evaluating whether nursing interventions were effective and for guiding subsequent care decisions, which supports continuity of care and patient safety [1]. When nurses document the response clearly, the next clinician can immediately see whether the action worked without having to infer it from raw data alone.References (research sources)

- [1]Effect of artificial intelligence on nursing documentation and patient safety.Research articleAlsararatee H. (2026) · DOI: 10.7748/ns.2026.e12724

## 임상 시나리오

DAR Focus Charting: The R ComponentDocumenting the client's response to nursing actions
In focus charting, each note has three parts: D (Data), A (Action), and R (Response). The R section records the client's reaction to the specific nursing action documented under A in the same note.

For a client with liver cirrhosis and ascites, an example of R would be: "No further vomiting for 2 hours; client states nausea is reduced" after an antiemetic was given.

CautionDo not confuse R in DAR with R in SOAP charting. In DAR, R is always the client's response, not a revision or future plan.

## 핵심 개념

- **Focus Charting** — A documentation system that organizes notes around a client concern or strength, using the DAR format.
- **DAR** — Acronym for Data, Action, Response; the three labeled parts of a focus charting note.
- **Response (R)** — The client's reaction to the nursing action taken, closing the loop of the nursing process in the note.
- **Data (D)** — Subjective and objective findings that support the identified focus of the note.
- **Action (A)** — The specific nursing interventions performed in response to the focus.

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