- Patient Identification: Name, age, room number, and medical record number. - Current Condition: Vital signs, symptoms, and any changes in the patient’s status. - Treatment and Medications: Details of administered medications, treatments, and their effects. - Assessments: Physical, emotional, and psychological assessments. - Plans and Recommendations: Future plans for treatment and any special instructions or recommendations. - Interventions: Any actions taken, such as wound care, catheter changes, etc.
