Documentation Examples for GI System Procedures
Date & Time Patient unable to eat and swallow for 2 weeks; explained to patient MD order for NGT insertion for tube feedings. Abdomen nondistended, soft, nontender; BS normoactive X4 quads; breath sounds CTA throughout. Salem sump 14 Fr NGT inserted in R. nare; 32cm of exposed tube. Aspirated small amount olive green GI secretions; pH 3. NGT clamped until confirmation CXR completed. Patient states minimal discomfort during NGT insertion; resting quietly now without any sign of distress; denies any c/o
Bolus Tube Feeding:
Date & Time Abdomen nondistended, soft, nontender; BS normoactive X4 quads; breath sounds CTA throughout. NGT placement confirmed with aspiration of small amount green GI secretions; pH 4. Bolus of 120 mL Ultracal supplement + 30 mL water flush given via NGT. NGT clamped. Tolerated feeding without any nausea or sign of distress. Resting quietly now with HOB elevated 45 degrees
Date & Time Abdomen nondistended, soft, nontender; BS normoactive X4 quads. DC’d NGT per order; entire NGT intact upon removal. Patient denied any discomfort during procedure. Oral and nare care provided. Resting quietly now without sign of distress; denies any c/o
Date & Time Abdomen slightly distended, slightly firm; nontender; BS hypoactive X4 quads. Last BM 4 days ago. c/o feeling of abdominal fullness; received MD order for 500 mL tap water enema. Patient able to retain water for 10 minutes. Returned large amount brown liquid with moderate amount hard brown stool on BSC. States minimal discomfort during enema, and abdomen feels much better. Resting quietly now in bed without any sign of distress.