What Are the Key Components of Nursing Documentation?
Key components of nursing documentation include:
Patient identification: Accurate recording of the patient’s name, age, gender, and other identifying information. Assessment data: Detailed records of physical, emotional, and psychological assessments. Nursing diagnoses: Documentation of clinical judgments about the patient’s health status. Care plans: Detailed plans outlining the nursing interventions and expected outcomes. Progress notes: Regular updates on the patient’s condition and the care provided. Discharge planning: Documentation of the patient’s readiness for discharge and any follow-up care required.
