SAMPLE DAR CHARTING: DELIVERY ROOM12/13/11 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 30seconds to 1 minute duration. Mild to moderate discomfort. 1:30 PM, IE done
by__________ revealed 60% effacement, 4cms 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 withIE and IVF insertion and
regulated to prescribed rate, perineal care done, 2 PM, Buscopan 1 tablet every hour started.
DBEdemonstrated. Instructed client to walk around the room.R: "Tumitindi ang sakit ng tiyan ko."
DBE done by patient when in pain. ______________ Initals4PM FOCUS: Second and Third LaborD:
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. Coachingof patient done. Kept
newborn on mother's chest warm by ___________. Application of perineal pads after perineal
caredone. Newborn taken by RN __________, transferred patient to stretcher. 4:23 pm, towards
with student nurse

_____________. _____________Initials

Admitted a case of name, age, sex, GP from address due to labor

pains/prematurerupture of membranes/ pre-eclampsia/ eclampsia/ severe bleeding/
intrauterined e a t h /
p l a c e n t a
p r e v
t r a n s i t
d e l i v e r y .

F:
Labor pains/Altered comfort
D:
grimaced face noted, kept on massaging her back, strong regular contractionsobserved, profuse perspiration
noted, full cervical dilatation and effacement noted,increased respirations noted.
A:
ushered to delivey room, mounted on the delivery table, positioned in lithotomyposition, perineal preparation
done, aseptically placed leggings and baby's receiveron mother's abdomen, coached on how to bear down
properly, assisted resident
ond u t y d u r i n g e p i s i o t o m y, s u p p o r t e d p e r i n e u m p r o p e r l y, d e l i v e r e d a n a l i v e b a b y g e n d
e r a t t i m e , d e l i v e r e d t h e p l a c e n t a i n D u n c a n / S c h u l t z m e c h a n i s m a t t i m e , assisted
resident on duty on the manual exploration of the uterus, postpartum BPtaken:reading (admistered
Methergine 1 amp IM as ordered), put on a diaper
andc
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e
r
,
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to breastfeed baby, placed ice pack over hypogastrium, monitor vital signs.
R:
with well contracted uterus and slight vaginal bleeding, still for continuous postpartum care