1. Patient Information: Name, age, gender, and medical history. 2. Nursing Assessments: Initial and ongoing assessments. 3. Care Plans: Detailed plans for patient care, including goals and interventions. 4. Medications: All administered medications, dosages, and times. 5. Procedures: Details of any procedures performed. 6. Patient Responses: Observations of patient responses to treatments and medications. 7. Communication: Any communication with other healthcare providers, patients, and families.
