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Box 18-5

Chart Smart

If your patient has burns, document the following information:

  • assessment findings
  • depth, extent, and severity of burn injury
  • extent of edema
  • pertinent laboratory results
  • IV therapy
  • urinary output
  • other interventions such as wound care
  • support provided to the patient and caregiver
  • patient and caregiver teaching along with the patient's response.