Accurate and timely documentation is essential. Nurses should use standardized forms and electronic health records (EHR) to ensure consistency. Key elements to include are:
- Date and Time: Precise timing of the observation. - Objective Data: Factual information such as vital signs. - Subjective Data: Patient's reported symptoms or feelings. - Nurse's Assessment: Professional judgment based on observations. - Interventions and Outcomes: Actions taken and their results.
