Diseases and Disorders
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Cholecystitis and Cholelithiasis

DOCUMENTATION GUIDELINES

• Physical response: Patency of airway; adequacy of breathing and circulation; vital signs; use of splinting or other measures to control pain while performing deep breathing

• Pain: Location, duration, quality, response to pain medications

• Type and amount of drainage from Penrose drain or T tube

• Condition of surgical incision and surrounding skin

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