Patient Information: Basic details such as the patient's name, age, medical history, and current condition. Assessment Data: Detailed findings from the initial and ongoing assessments. Diagnosis: Identified nursing diagnoses based on the assessment data. Goals and Outcomes: Both short-term and long-term goals, along with the desired outcomes. Interventions: Specific actions that will be taken to achieve the goals. Evaluation: Criteria for evaluating the effectiveness of the interventions and progress toward goals.
