Documentation Guidelines

• Findings of physical exam and ongoing assessments: Nausea, vomiting, anorexia, diarrhea, color of stools and urine, daily weights, vital signs, jaundice, pruritus, edema, ascites, pain, level of consciousness

• Response to medical and nursing interventions: Medications, comfort measures, diet, hydration

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

• Presence of complications: Bleeding, progressive liver degeneration, changes in mental status

• Protection of household: Isolation procedures, family prophylaxis

0 0

Post a comment