Journal of emergency nursing : JEN : official publication of the Emergency Department Nurses Association
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Hypothermia is a common complication occurring in seriously injured patients. Emergency department and prehospital protocols governing the care of trauma patients should include the assessment of core temperature and the management of hypothermia so that it does not go unrecognized and untreated.
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The medical record serves numerous functions. It provides chronologic evidence of patient evaluation, treatment, and response to therapy, and a means to review the quality of the care. Communication among members of the health care team regarding the patient's status and plan of care also occurs by means of the medical record. ⋯ For the trauma patient, mechanisms of injury, GCS, trauma score (or essential components), spinal immobilization, and the status of airway, breathing, and circulatory systems also must be recorded. The importance of accurate and comprehensive documentation on every medical record should not be underestimated. (National Standards of Emergency Nursing Practice dictate that nurses are responsible for the accurate documentation of patient care.) The medical record provides both important information about the patient's clinical condition and the corner-stone for lawsuits in alleged medical negligence. It is the legal documentation of ongoing patient care delivery and the chronicle of the patient's responses to therapeutic interventions.