Documentation Guidelines

• Respiratory and cardiovascular functions: Patency of airway, description of breathing, vital sign changes with rest or activity

• Neurological functions: Level of paralysis, level of motor and sensory function, level of consciousness

388 Gunshot Wound

• Bowel and bladder functions: Frequency of voiding, consistency and number of stools

• Pain: Location, duration, precipitating factors, interventions that alleviate pain

• Activity: Strength and motion of extremities, presence of deformities or atrophy and strategies used to manage dysfunction, response to activity

• Skin: Areas of potential or actual breakdown, successful strategies to manage breakdown

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