Documentation of nursing diagnoses is essential for maintaining accurate patient records and facilitating communication among healthcare providers. Nurses typically document diagnoses in the patient's medical record, often using electronic health record (EHR) systems. This documentation includes:
1. The Nursing Diagnosis: Clearly stated in standardized terminology. 2. Related Factors: Conditions or situations that contribute to the diagnosis. 3. Defining Characteristics: Signs and symptoms that support the diagnosis. 4. Interventions and Goals: Planned actions and expected outcomes.
