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nursing documentation

Verify patient’s name, date of birth, and medical record number

Document date and time of the entry

Include the name and designation of the nurse documenting

Record vital signs (temperature, pulse, respiration, blood pressure)

Note any relevant physical examination findings

Document patient’s chief complaint and history of present illness

Outline nursing diagnoses based on assessment findings

Specify measurable goals and expected outcomes

List nursing interventions and rationale for each

Document all care provided, including medications administered

Record patient education provided and patient’s understanding

Note any changes in patient status or responses to interventions

Assess the effectiveness of nursing interventions

Document progress towards goals and outcomes

Update care plan as necessary based on evaluation findings

Note any communication with other healthcare team members

Record patient and family involvement in care decisions

Document any referrals made to other services

Ensure all entries are clear, concise, and objective

Avoid using abbreviations that may cause confusion

Sign all entries with name and designation, and ensure compliance with facility policies

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