| Section | Subsection | Row Name (20 Char) | Row (f, a, n) f=Fixed a=Automatic n=Normal | Lists: short name (7 char) | Lists: Long name (16 char) | ||
| GI/GU | GI Basic | GI Assessment | N |
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| Nutrit | Assessment | Abdomen | N | ||||
| Abd. Auscultate Site | N | ||||||
| Abdominal Tone | N | ||||||
| Bowel Sounds | N | ||||||
| Diet | A | ||||||
| Tube Feed Strength | N | ||||||
| Appetite | N | ||||||
| % Diet Taken | N | ||||||
| Feeding | N |
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| Dentures | N | ||||||
| Oral Mucosa | N | ||||||
| Stool Amount | N | ||||||
| Stool Color | N | ||||||
| Stool Consistency | N | ||||||
| GI Complex | Abdominal Pulsation | N |
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| Assessment | Abdominal Percussion | N | |||||
| Abdominal Palpation | N | ||||||
| Abdominal Cramping | N | ||||||
| Flatulence | N | ||||||
| Nausea | N | ||||||
| Nausea Relief | N | ||||||
| Emesis | N | ||||||
| Gastric Drainage | N | ||||||
| Ascites Girth | N | ||||||
| Dysphagia | N |
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| Oral Lesion/Site | N | ||||||
| Abnl GI Elimination | N | ||||||
| Bowel Appliance | N | ||||||
| Ostomy Type | N | ||||||
| Stoma Appearance | N | ||||||
| GI Problems | Altered Comfort R/T: | N |
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| Altered Feed Route | N | ||||||
| aka dysphagia | Impaired Swallowing | N | |||||
| Altered Nutrition | N | ||||||
| Altered GI Eliminatn | N | ||||||
| E-lyte Imbalance | N | ||||||
| Alt. Tissue Perfusn | N | ||||||
| Imp. Tissue Integrty | N | ||||||
| Fluid Volume Deficit | N | ||||||
| Knowldge Deficit R/T | N | ||||||
| GI Interventions | DKA SOC | N |
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| GIB SOC | N | ||||||
| TPN/PPN Protocol | N | ||||||
| NG Policy&Procedure | N | ||||||
| Tube Feeding P&P | N | ||||||
| Tube Feed Hold/DC | N | ||||||
| Oral/Denture Care | N | [1] | |||||
| Weight/s | N | ||||||
| Aspirate Precautions | N | ||||||
| Diet Supplements | N | ||||||
| Disimpaction | N | ||||||
| Enema Type | N | ||||||
| GI Referral | N | ||||||
| Referral Status,GI | N | ||||||
| GI Teaching | Teaching, GI | N |
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| Taught to Whom, GI | N | ||||||
| Response, GI | N | ||||||
| Additional Needs, GI | N | ||||||
| GI Outcomes | Nutrient Needs Met | N |
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| No Nausea/Vomiting | N | ||||||
| Tolerates Diet/TF | N | ||||||
| Regular Bowel Pattrn | N | ||||||
| Abd Soft/Nontender | N | ||||||
| No Abd Distention | N | ||||||
| No Incontinence | N | ||||||
| Normal Chewing | N | ||||||
| Normal Swallowing | N | ||||||
| Bowel Sounds Present | N | ||||||
| No Tubes/Drains | N | ||||||
| No Ostomies | N | ||||||
| GU Basic | GU Assessment | N |
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| Assessment | Urine Source | N | |||||
| Urine Color | N | ||||||
| Urine Character | N | ||||||
| Bladder | N | ||||||
| Menses | N | ||||||
| GU Complex | Abnl GU Elimination | N |
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| Assessment | Urinary Frequency | N | |||||
| Urinary Incontinence | N | ||||||
| Urine Odor | N | ||||||
| Bladder Irrigation | N | ||||||
| Stoma Appearance | N | ||||||
| Dialysis Type | N | ||||||
| Genital Edema | N | ||||||
| Genital Discharge | N | ||||||
| Fetal Heart Tones | N | ||||||
| Fundus Check | N | ||||||
| Fundus Location | N | ||||||
| Lochia | N | ||||||
| GU Problems | Altered GU Eliminatn | N |
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| Impair Renal Functn | N | ||||||
| >Risk Infection | N | ||||||
| >Risk Skin Breakdwn | N | ||||||
| Self Care Deficit | N | ||||||
| Knowldge Deficit R/T | N | ||||||
| GU Interventions | Foley Cath SOC | N |
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| Hemodialysis SOC | N | ||||||
| Peritoneal Dialy SOC | N | ||||||
| CRRT SOC | N | ||||||
| CBI SOC | N | ||||||
| Offer Toileting Q__ | N | ||||||
| Bladder Training | N | ||||||
| Straight Cath | N | ||||||
| GU Teaching | Teaching, GU | N |
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| Taught to Whom, GU | N | ||||||
| Response, GU | N | ||||||
| Additional Needs,GU | N | ||||||
| GU Outcomes | Nl Urinary Function | N |
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| Clear Yellow Urine | N | ||||||
| DC Urinary Drains | N | ||||||
| Intact Skin | N | ||||||
| No Urinary Infection | N | ||||||
| No Genital Drainage | N | ||||||
| note: Implement Ap | |||||||
| Specialty Diet | |||||||
| date of last BM- pr | |||||||