Nursing notes typically include several key components to ensure comprehensive documentation:
1. Patient Information: Basic details such as name, age, gender, and medical record number. 2. Assessment Findings: Observations, vital signs, and physical examination results. 3. Interventions: Actions taken, medications administered, and treatments provided. 4. Evaluation: Patient's response to interventions and any changes in condition. 5. Plan: Future care plans, follow-up actions, and any instructions given to the patient or family.
