Documentation Guidelines

• Physical findings: Neurological deficits, level of orientation, Glasgow Coma Scale, pupil responses, gait, range of motion, gag reflex, visual deficits

• Ability to communicate verbally and nonverbally

• Ability to perform self-care; bowel and bladder control

• Presence of complications, infections, contractures, skin breakdown

• Emotional response: Ability to cope, presence of depression, ability to socialize with others, anxiety and frustration over speech difficulties

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