By Editorial Team Last updated: Jan 14, 2022
You will perform a history of an abdominal problem one that you have experienced and perform an assessment of the gastrointestinal system. You will document your subjective and objective findings, identify actual or potential risks.
Remember to be objective when you document; do not make judgments. For example, if the person has a palpably enlarged liver, do not write "the liver is enlarged probably because they drink too much." Avoid stating that something is normal but instead state WHY you think it is normal. For example, if you think that the abdomen looks "normal" - which is subjective - then document that the “abdomen is flat, skin color consistent with rest of body, no lesions, scars, bulges, or pulsations noted."
Title:
Documentation of problem based assessment of the gastrointestinal system.
Purpose of Assignment:
Learning the required components of documenting a problem based subjective and objective assessment of gastrointestinal system. Identify abnormal findings.
Course Competency:
Prioritize appropriate assessment techniques for the gastrointestinal, breasts, and genitourinary systems.
Instructions:
Content: Use of three sections:
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