Documentation of an 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.”

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