Documentation Guidelines

• Physical response: Location, size and appearance of wound; description of dressings and drainage on dressings; amount of bleeding from wound; description of accompanying injuries, breath sounds, heart sounds

• Response to treatment: Vital signs, pulse oximetry, urine output, mental status, patency of airway, adequacy of circulation

• Presence of complications: Infection, hemorrhage, organ dysfunction, poor wound healing

• Pain: Location, duration, precipitating factors, response to interventions

• Laboratory results: Electrolytes, measures of organ function, complete blood count, coagulation studies

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