Documentation Guidelines

• Physical assessment findings:

Neurological: Mental status response to stimuli; if pharmacologically paralyzed, then peripheral nerve stimulation testing Pulmonary: Respiratory rate, auscultation findings, amount of ventilatory support, oxygen saturation by pulse oximetry Hemodynamics: Cardiac output/index, right and left ventricular measures of preload and after-

load; oxygen delivery; oxygen consumption Renal function: Fluid intake and urine output

Hepatic function: Color of skin and sclera, presence of petechiae, bruising, oozing, or frank bleeding

• Response to acute, life-threatening illness: Anxiety level, coping

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