assess for injuries:

How Do You Document Injury Assessments?

Proper documentation is essential for continuity of care and legal purposes. Nurses should ensure:
- Accuracy: Document findings precisely and include the time of assessment.
- Detail: Provide detailed descriptions, including measurements and observations.
- Use of Standard Forms: Utilize standardized forms and checklists where available to ensure completeness.
- Confidentiality: Maintain patient confidentiality and follow HIPAA guidelines.

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