Nursing documentation should be comprehensive and include the following:
Patient Identification: Name, date of birth, and medical record number. Assessment Data: Vital signs, physical examination findings, and patient history. Nursing Diagnoses: Identified health problems based on assessment data. Care Plan: Goals, expected outcomes, and planned interventions. Interventions: Actions taken by the nurse, such as administering medication or providing wound care. Evaluation: Patient's response to interventions and progress towards goals.
