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 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)

• Patient's and family's understanding of and interest in patient teaching

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