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, 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), cerebral perfusion pressure (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: Stabilizations of vital signs, changes in neurological status

• Response to medications used to control pain and increase ICP

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