What Should Be Included in Clinical Documentation?
Nursing clinical documentation should be comprehensive and include the following elements:
Patient Information: Name, age, gender, and other identifying details. Medical History: Previous illnesses, surgeries, and current medications. Assessment: Initial and ongoing assessment of the patient's condition, including vital signs and physical examination findings. Care Plan: Detailed plan of care, including nursing diagnoses, interventions, and expected outcomes. Progress Notes: Daily notes documenting the patient's progress, any changes in condition, and the care provided. Discharge Summary: A summary of the patient's stay, including their condition on discharge, instructions for follow-up care, and any prescribed medications.
