Every intervention and teaching action requires a documented response that closes the loop. An intervention without a reassessment is an audit gap.
Quantified effect of each intervention — for example, BP 168/96 → 142/84 after rest and a PRN dose; edema 3+ → 2+; weight ___ → ___; chest pain 6/10 → 0/10 after nitroglycerin.
Tolerance and any adverse effects of administered medication.
Teaching effectiveness: teach-back percentage or return-demonstration result, and any gap requiring reinforcement.
Functional response, such as ambulation distance before and after.
The plan for reassessment timing and what will be re-evaluated at the next visit.
