Documentation Guidelines

• Physical responses: Vital signs, cardiopulmonary assessment, neurological assessment, mental status, presence or absence of petechiae

• Emotional response: Coping strategies, mood, affect, flexibility, cooperation

• Presence of complications: Fever, infection, skin breakdown, loss of consciousness

• Ongoing monitoring: Pulse oximetry or arterial blood gases (ABG) results that are abnormal, abnormal laboratory findings

• Response to treatment: Mechanical ventilation, response to fluid replacement and medications, response to supplemental oxygen

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