What must you document at the end of a patient's care?

Documenting the Plan of Care Review and an outcome is essential because it summarizes the patient's progress and the effectiveness of the treatments administered. This documentation serves as a crucial communication tool among healthcare providers, ensuring that all team members are aware of the patient's status and any changes to the treatment plan. Including the outcomes helps to evaluate the success of interventions and informs future care decisions, making it a vital part of maintaining patient safety and quality of care.

Other options, while they contain important information, do not specifically address the critical need to assess and document the results of the care provided. For instance, documenting medical history and insurance details is necessary for administrative purposes but does not reflect the patient's immediate therapy outcomes. Similarly, documenting medications and discharge instructions is important for continuity of care, but it does not provide a comprehensive overview of the patient's response to treatment as the Plan of Care Review does. Lastly, noting the names of staff involved in the care can enhance accountability but falls short of evaluating the care's effectiveness. Therefore, the completeness of care documentation culminates in the review of the care plan and recorded outcomes.