nursing notes
Patient care documentation
Nursing notes are the written records nurses make documenting a patient's condition, care provided, and responses to treatment.
They form part of the medical chart and serve both clinical and legal purposes—tracking changes over time and establishing that proper care was given.
The nursing notes showed the patient's temperature spiked at 2 AM.
- chartingRecording data visually
- documentationWritten proof or instructions
- patientAble to wait calmly
- vital signsMeasurable life indicators
- vitalsBasic body measurements
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