Documentation Guidelines

• Physical findings: Bleeding, abdominal enlargement, weight gain or loss, fluid intake and output, easy respirations, breath sounds, heart sounds, level of consciousness, gastrointestinal status (nausea, vomiting, anorexia, diarrhea), color of skin and sclera

• Laboratory results: White blood cell count, hemoglobin and hematocrit, albumin, serum electrolytes, ALT, AST

• Nutrition: Tolerance of diet, appetite, ability to maintain body weight

• Response to treatment: Medications, surgery, pericentesis

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