What should be documented following a patient assessment?

Documenting findings following a patient assessment is crucial for ensuring continuity of care and effective communication among healthcare providers. This includes not only the objective data such as vital signs but also subjective data such as patient complaints and responses to interventions.

By documenting findings, healthcare professionals have a comprehensive record that includes the patient's condition at the time of assessment, the interventions that have been performed, the responses of the patient to those interventions, and any changes in their condition over time. This holistic approach allows for better tracking of the patient's progress, aids in decision-making for future care, and ensures that all team members have access to the same information.

Such thorough documentation is essential for legal purposes as well, as it provides a clear account of the care provided and the rationale for clinical decisions made. This level of detail in documentation helps improve patient safety and care outcomes.