Documentation of problem based assessment of the gastrointestinal system.

You will perform a history of an abdominal problem that your instructor has provided you or 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, and submit this in a Word document to
the drop box provided.
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.”
GI study
Mary Cole, a 50-year-old female with a known history of ulcerative colitis (UC) and anemia, was driven to
the emergency department (ED) by her daughter, Cindy, on April 11, 2019, just after 1000. The reason for
her visit was due to complaints of severe abdominal pain/swelling and bloody diarrhea over the past four
days.
Vital signs were taken in the ED showing a blood pressure (BP) of 96/50, heart rate (HR) 113 bpm,
respiratory rate (RR) of 29, tympanic temperature of 38.9°C, oxygen saturation (O2 sat.) of 97% on room
air, and a pain of 9/10 (using the verbal numeric pain scale) located in her left lower abdominal quadrant
that is sharp, constant, and aggravated by movement. Mary states, “my stomach hurts so much I can
barely take the pain”. She claims that she has been taking extra-strength Advil (ibuprofen 400mg) for the
pain.

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:
o Subjective
o Objective
o Actual or potential risk factors for the client based on the assessment findings with description or reason for selection of them.

Format:
• Standard American English (correct grammar, punctuation, etc.)

Resources:
Chapter 5: SOAP Notes: The subjective and objective portion only
Sullivan, D. D. (2012). Guide to clinical documentation. [E-Book]. Retrieved from http://ezproxy.rasmussen.edu/login?url=http://search.ebscohost.com/login.aspx?direct=true&db=nlebk&AN=495456&site=eds-live&ebv=EB&ppid=pp_91 >

Smith, L. S. (2001, September). Documentation do’s and don’ts. Nursing, 31(9), 30. Retrieved from http://ezproxy.rasmussen.edu/login?url=http://search.ebscohost.com/login.aspx?direct=true&db=rzh&AN=107055742&site=eds-live

Documentation Grading Rubric- 10 possible points
Levels of Achievement
Criteria Emerging Competence Proficiency Mastery
Subjective
(4 Pts) Missing components such as biographic data, medications, or allergies. Symptoms analysis is incomplete. May contain objective data.
Basic biographic data provided. Medications and allergies included. Symptoms analysis incomplete. Lacking detail. No objective data. Basic biographic data provided. Included list of medications and allergies. Symptoms analysis: PQRSTU completed. Lacking detail. No objective data. Information is solely what “client” provided. Basic biographic data provided. Included list of medications and allergies. Symptoms analysis: PQRSTU completed. Detailed. No objective data. Information is solely what “client” provided.
Points: 1 Points: 2 Points: 3 Points: 4
Objective
(4 Pts) Missing components of assessment for particular system. May contain subjective data. May have signs of bias or explanation of findings. May have included words such as “normal”, “appropriate”,
“okay”, and “good”.
Includes all components of assessment for particular system. Lacks detail. Uses words such as “normal”, “appropriate”, or “good”. Contains all objective information. May have signs of bias or explanation of findings. Includes all components of assessment for particular system. Avoided use of words such as “normal”, “appropriate”, or “good”. No bias or explanation for findings evident Contains all objective information Includes all components of assessment for particular system. Detailed information provided. Avoided use of words such as “normal”, “appropriate”, or “good”. No bias or explanation for findings evident. All objective information
Points: 1 Points: 2 Points: 3 Points: 4
Actual or Potential Risk Factors
(2 pts)
Lists one to two actual or potential risk factors for the client based on the assessment findings with no description or reason for selection of them. Failure to provide any potential or actual risk factors will result in zero points for this criterion. Brief description of one or two actual or potential risk factors for the client based on assessment findings with description or reason for selection of them. Limited description of two actual or potential risk factors for the client based on the assessment findings with description or reason for selection of them. Comprehensive, detailed description of two actual or potential risk factors for the client based on the assessment findings with description or reason for selection of them.
Points: 0.5 Points: 1 Points: 1.5 Points: 2