These are some notes my peers and I tend to write on some brief examples to give you some examples:
ABT therapy: Pt. on ABT tolerating therapy [insert name/dosage/route] with no adverse reactions noted. [temperature and other vitals that you may think is pertinent].
Lung sounds auscultated with findings, skin temperature ( is the patient flushed?) findings.
If on IV: additionally, IV line patent, no s/s of phlebitis and infiltration.
( refusal of care)
Pt. found to self remove [apparatus] ( such as sling or abductor pillow, very major points of care). Education on [apparatus] ( specifically what you may have explained). Patient states understanding, " jfhsdkfhsjkf" but continues to non-adhere to precautions. Reapproached and stressed importance, patient continues to refuse. [ Other interventions you may have to do to maintain patient safety.] MD called/made aware. Will continue to monitor ( any vitals or pulses that may be pertinent).
Documenting IV and refusal of care has saved my butt many times ( not a lot of phonecalls!) and I hope this helped.