What Should Be Included in Comprehensive Documentation?
Comprehensive documentation should include the following elements:
Patient information: Demographics, medical history, and current health status. Assessment data: Vital signs, physical examination findings, and diagnostic test results. Care plans: Goals of care, interventions planned, and expected outcomes. Interventions: Details of the care provided, including medications administered, treatments performed, and patient education given. Evaluation: Patient's response to interventions, changes in condition, and progress towards goals. Communication: Notes on communications with other healthcare providers, family members, and the patient.
