Documentation Guidelines

• Physical changes: Weight, mental status, vital signs, skin integrity, bowel habits

• Tolerance to activity, fatigue, ability to sleep, ability to manage self-care

• Emotional response, coping, signs of ineffective coping, support from family and friends

• Presence of opportunistic infections, complications of infections, medications, resistance, recurrence

• Requests for management of the critical phases of disease, and pertinent information about the patient's wishes regarding the final stages of life

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