Documentation Guidelines

• Response to the diagnosis of cancer, the diagnostic tests, and recommended treatment regimen

• Physical responses: Patency of airway, neurological assessments, vital signs, signs of increased ICP or seizure activity, description of all dressings and wounds, appearance of incision

• Response to and tolerance to therapy: Radiation, surgery, chemotherapy

• Presence of complications: Increased ICP, hemorrhage, infection, pulmonary congestion, activity intolerance, unrelieved discomfort

• Activity level, progress in rehabilitation if appropriate, ability to perform independent activities of daily living

148 Breast Cancer

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