What are the Components of Standard Nursing Documentation?
The standard nursing documentation typically includes the following components:
Patient Identification: This includes the patient's name, age, gender, medical record number, and other identifying information. Assessment: Detailed observations and assessments of the patient's condition, including vital signs, physical examination findings, and any relevant history. Nursing Diagnosis: Identifying and documenting the patient's health problems and potential issues based on the assessment. Planning: Setting measurable and achievable goals for the patient's care. This includes formulating care plans and interventions. Implementation: Documenting the care and interventions provided to the patient, including medications administered, procedures performed, and patient education. Evaluation: Assessing the patient's response to the care provided and documenting any changes or progress towards goals.
