What are the Key Components of Enhanced Documentation?
Key components include:
1. Patient Assessment: Documenting initial and ongoing assessments, including vital signs, physical examinations, and patient history. 2. Care Plans: Detailed care plans outlining nursing interventions, goals, and expected outcomes. 3. Interventions: Recording all interventions performed, such as medication administration, wound care, and patient education. 4. Patient Responses: Documenting patient responses to interventions, including any changes in condition or adverse reactions. 5. Communication: Notes on communication with patients, families, and other healthcare providers. 6. Discharge Planning: Detailed discharge instructions and follow-up care plans.
