A PMHNP prescribes a second-generation antipsychotic to a 45-year-old male patient with schizophrenia. Six months later, the patient is diagnosed with new-onset type 2 diabetes mellitus. The patient's attorney files a malpractice claim alleging that the PMHNP failed to meet the standard of care. A review of the medical record reveals that the PMHNP documented an informed consent discussion about side effects at the initial visit but did not document any metabolic monitoring laboratory values during the six months of treatment. Which element is most critical in determining whether the PMHNP met the standard of care?