What are the Components of Comprehensive Nursing Documentation?
Comprehensive nursing documentation typically includes several key components:
Patient Identification: Name, Date of Birth, and Medical Record Number. Admission Data: Reason for admission, initial assessment, and history. Ongoing Assessments: Vital signs, pain assessments, and other routine checks. Interventions: Medications administered, procedures performed, and care provided. Outcomes: Patient's response to interventions, changes in condition, and discharge planning.
