Introduction to documentation

Documentation requirements will vary between clinical practice settings.  In some settings, documentation typically follows a SOAP format.

Therapy intervention for a child with a burn often involves the application of devices (i.e. pressure garment, compression bandaging, splinting) that if applied incorrectly or if the position on the child changed due to the child moving, may cause harm to the child.  Given this, strict documentation clearly outlining wearing regimes, frequency of monitoring,  what to look for when monitoring, indicators for device removal and precautions of use must be recorded clearly in both medical records and provided to family/ward staff.