A PMHNP is prescribing clozapine for a 35-year-old man with treatment-resistant schizophrenia who has failed adequate trials of three other antipsychotics. During a routine follow-up, the patient mentions intermittent constipation over the past two weeks but denies abdominal pain, distention, or changes in bowel habits beyond decreased frequency. His ANC is within normal limits. The PMHNP advises increased fluid and fiber intake and schedules follow-up in two weeks. One week later, the patient presents to the emergency department with clozapine-induced ileus requiring surgical intervention. Which documentation element would be most critical for the PMHNP's malpractice defense?