Documentation Guidelines

• Trauma history, description of the event, time elapsed since the event, whether the patient had a loss of consciousness and, if so, for how long

• Adequacy of airway, breathing, circulation; serial vital signs

• Appearance: Bruising or lacerations, drainage from the nose or ears

• Physical findings related to the site of head injury: Neurological assessment, presence of accompanying symptoms, presence of complications

• Signs of complications: Seizure activity, infection (fever, purulent discharge from any wounds), aspiration pneumonia (shortness of breath, pulmonary congestion, fever, productive cough), increased ICP

• Response to medications used to control pain and increased ICP

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