What Are the Key Components of Accurate Documentation?
Accurate documentation should include several critical components. These are:
Patient Identification: Include the patient’s full name, date of birth, and medical record number to prevent any mix-ups. Objective Data: Document factual information such as vital signs, lab results, and physical examination findings. Subjective Data: Include the patient’s own words regarding their symptoms, feelings, and concerns. Interventions: Record all nursing interventions and treatments administered. Evaluation: Note the patient’s response to treatments and any changes in their condition. Time and Date Stamps: Ensure all entries are time-stamped and dated to provide a chronological record of care.
