Documentation Guidelines

• Bleeding episodes: Site, extent, duration, associated signs and symptoms, response to interventions

• Physical responses: Alteration in circulation, movement, or sensation; redness, warmth or swelling around joints; changes in vital signs, intake and output, cognition

• Pain: Location, precipitating factors, quality, intensity, associated signs and symptoms, factors that alleviate or exacerbate the pain

• Therapeutic and adverse effects of medical or surgical interventions

0 0

Post a comment