Documentation Guidelines

• Discomfort: Character, location, duration, severity, nonverbal indicators, strategies that reduce discomfort

• Behavior: Manifestations, signs of irritability, gait, amount of crying

• Patterns of rest and activity: Sleep patterns, presence of lethargy or restlessness

• Medication management: Parents' understanding of drug therapy, response to medications

• Response to teaching: Response to parenting suggestions, understanding of follow-up appointments

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