Documentation Guidelines

• Skin assessment: Presence of rash; description and location of rash

• Musculoskeletal assessment: Warmth, tenderness, stiffness, swelling of involved joints

• Cardiac assessment: Rate and regularity of rhythm; presence of chest pain, shortness of breath, palpitations, dizziness

• Neurological assessment: Headache, stiff neck, confusion, sensory loss, memory loss, facial weakness or paralysis, limb weakness

• Response to therapy: Relief of presenting symptoms (fever control, pain relief, resolved neurological and cardiac complications)

0 0

Post a comment