Documentation Guidelines

• Trauma history, description of the event, time elapsed since the event, whether or not the patient had a loss of consciousness, and if so, for how long

• Adequacy of airway, breathing, and 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 (decreased level of consciousness, unequal pupils, loss of strength and movement, confusion or agitation, nausea and vomiting), CPP, ICP

• 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 surgery and clot evacuation: Mental status changes, incisional healing, presence of complications (infection, hemorrhage)

0 0

Post a comment