Documentation Guidelines

• Physical findings related to gastric cancer: Epigastric discomfort, dyspepsia, anorexia, nausea, sense of fullness, gas pains, unusual tiredness, abdominal pains, constipation, weight loss, vomiting, hematemesis, blood in the stool, dysphagia, jaundice, ascites, bone pain

• GI decompression data: Irrigation and patency of tube, assessment of bowel sounds and passage of gas, complaints of nausea, amount and description of gastric fluid output

• Presence of postoperative complications: Hemorrhage, obstruction, anastomotic leaks, infection, peritonitis

• Presence of postoperative dumping syndrome and associated patient symptoms

0 0

Post a comment